APGAR meaning and scoring
Activity (muscle tone (0-2) Pulse (heart rate 0-2) Grimace (reflex irratibility 0-2) Appearence ( Skin colour 0-2) Respiration (breathing rate and effort 0-2)
Score given at 1 and 5 minutes post birth Score 0-10 Severely depressed 0-3 Moderately depressed 4-6 Excellent condition 7-10
APGAR score that remains low 10 minutes after birth are at a risk of neurological complications
Preterm birth and gestational ages
Preterm is birth of viable infant before 37 weeks of gestation
-Preterm birth and low borth weigbht combined increases the risk for neurological complications
Gestational age: Extremely preterm: <28 weeks Very preterm: 28-32 weeks Moderate to late pretem 32-37 weeks Term birth : 37 weeks (typically 38 to 41 weeks
Preterm babies adjusted age is based on 40 weeks gestation timelinbe
- subtract chikds chronological age from number of weeks they are bon prematureelly (subtracted from 40)
e. g chronolical age=20, weeks born premature=6 weeks, adjusted age=14 weeks
Assymetrical tonic neck reflex ATNR
Integration: 5 mnonths
Stimulus:turning head
response: Extenseion of UE and LE on the side the face is turned to
Rooting reflex
Integration: 3 months
Stimulus: Lightly stroking the perioratal area
response: Movement of head and lips towards the stimulus
Suck-swallow reflex
Integration: 5 months
Stimulus: touch to the inside of the mouth
response: rhythmic sucking and swallowing
palmar grasp
Integration: 7 months
Stimulus: pressure against the palm of the hand
response: Flexion of the fingers
Flexor withdraawal
Integration: 2 months
Stimulus: noxious stimulus to the bottom of the foot
response: Extension of the toes, ankle DF, knee and hip flex on stimulus side
Crossed extension
Integration: 2 months (inconsistent)
Stimulus: noxious stimulus to the bottom of the foot
response: flexion of LE on stimulated side and ext and adduction on the LE of contralateral side
Moro reflex
Integration: 5 months
Stimulus: Sudden head drop backwards
response: Extension and abduction of the UE with opening of the hands and crying, may be followed by flexion and adduction of UE
Positive support
Integration: 2 months (incomnsistent)
Stimulus: feet in contact with the floor
response: bilateral leg extension with bilateral support
Stepping refleex
Integration: 4 moths
Stimulus: supported upright vertical with fet in contact with flat surface
response: rhythmic high stepping movement
Landau
Integration: 24 months (2 years)
Stimulus: supported in prone with hands under thorax
response: head, neck, back, and LE exteension
Symmeetrical tonic neck reflex(STNR)
Integration: 12 months
Stimulus: flexion or extension of cervical spin
response: Cervical spinee flexion causes UE flexion & LE extension, C spine extension causes UE extension and LEE flexion
Milestones (Roll, sit, crawl, cruising, standing, walking, stair climbing (step to pattern), Running, kicking a ball, skipping
Roll (1st roll from prone to supine (3-6 months) sit: 6 months crawl: 8-9 months cruising: 9 months standing: 9 months walking: 10-15 months, stair climbing (step to pattern): 18-20 months Running: 2 years kicking a ball: 3 years skipping: 5 years
Alberta infant motor scale (AIMS)
0-18 months
-motor skills
Bayley scasle of infant motor development (BSID)
- 1-42 months
- mental, motor, and behavior scales
Peabody development motor scales (PDMS-2
- 0-60 months
- Fine and gross motor skills
Bruininks oseretsky tests for motor performance (BOT-2)
- 4 - 21 years
- fine and gross motor skills
- Can test and document longitudinal impact of condition on motor function
Down syndrome (Trisomy 21)
-Genetic diisorder caused by faulty cell division resulting in an extra 21st chromosome
-mild developmental delay, follows normal developmental curve but is just slightlydelayed
-Mild to moderate intellectual delay
Distinct facial features:
1)Flattened nose
2) Small mouth and jaw
3) Narrow eyes
4) Protruding tongue
Will have increased ligament laxciity and hypotonia, need to bee aware for mobilizations bc atlantoaxcial joint could lead to a high level SCI
Cerebral palsy
-Describes a group of permanent disorders of the development of movement and posture, that lead to non-progressive disturbances that occurred in the developing fetal or infant brain.
Risk factors:
- Prematurity (linked to periventricular leukomalasia)
- Atypical intrauterine growth
- infection (in utero & post-natal)
- Infarction of the mother
- developmental defect
- Multiple gestations
- placental pathology
- trauma (prenatal, perinatal, early postnatal)
-Spastic type CP is the most common
Type of impairment
Spastic
- velocity-dependent resistance to movement
- Damage to the cortex or white matter to and from the sensorimotor cortex
- Most common type of CP
- Positive UMN syndrome
- Diplegia is the most common type of spastic CP (scissoring gait, and toe walking)
Dyskinetic
Ataxia:
-Movement disorder characterized by intention tremor, lack of muscle control,, and poor coordination of voluntary movements
-Most children with ataxic CP can walk without a gait aid but may have difficulty with balance
Athetosis:
- Movement disorder characterized by slow, continuous, involuntary writhing movements
- Commonly affects the distal extremities and the mouth
- Difficulty maintaining a stable posture
- significant limitation in gross motor function
Dystonic
- Movement disorder characterized by involuntary sustained or intermittent muscle contractions leading to repetitive movements, abnormal fixed postures, and disordered tone
- May include twisting or tremulous movements
- dystonic posture: co-contraction of muscles making a sustained abnormal posture
- often triggered by voluntary movement
- significant limitations in gross motor function and fatigue due to high metabolic demand
Mixed:
- Combination of dyskinetic and spastic CP
- Diffuse injury to the motor cortex and basal ganglia
GMFCS for CP
scale is considered stable after 2 years old
Level 1: Walks without restrictions, limitations in more advanced gross motor skills
Level 2: Walks without devices, limitations in walking outdoors and in the community
Level 3: Walks with mobility devices, limitations in walking outdoors and in the community
Level 4: Self mobility with limitations, children are transported or use a power mobility outdoors and in the community
Level 5: Self mobility is severely limited, even with the use of supporting technology
AFOs for CP
Solid AFO: Blocks ankle movement at talocrural and subtalar joints
- often used with rocker bottom shoe
- limits knee hyperextension
- Indicated for correctable equinus, and excessive DF
Hinged (srticulated) AFO
- Allows controlled DF while still limiting PF
- Limits movement at subtalar joint
- Limits knee hyperextension
- Indicated for true equinus that isn’t fixed, drop for, medial lateral instability
Geound reaction force AFO
- Blocks movement at the talocrural joint and limits subtalar movement
- Increases knee extension
- Good for crouch gait, with weak quads, and overlengthened calf muscles
Duchene muscular dystrophy (DMD)
Genetic disorder characterized by progressive weakening and degeneration of muscle leading to activity limitations and participation restriction
- Mutation of the dystrophin gene
- Life expectancy is 20-30 years
Typical presentation:
- Clinical signs become apparent at 2-5 years old
- early motor milestones are achieved at expected ages (Difficulty with walking at 6-8 y.o)
- Impairments become more apparent with higher level gross motor activities (difficulty with run ning at 2-6 y.o)
- 8-12 y.o wheelchair dependent
- 12 y.o completely dependent
Progressive muscle weakness and wasting
- Lower limbs>upper limbs
- proximal>distal
- muscles of face, eyes, speech and swallowing and sphincter typically not involved
S & S:
- Waddling gait
- Psudohypertrophy of calves
- Gowers sign
- Toe walking
- Lumbar Hyperlordosis
- Wide stance with ER of LE
PT management
- Avoid aggressive strengthening (esp eccentric contraction)
- Strengtheing and ROM
- Gait training (try to prolong ambulation not fix it)
- Education on overexertion and energy conservation
- Respiratory exercise (breath stacking, assistive cough, and incentive spirometer)
- Transfer training
- Equipment selection (wheelchair, transfer lifts, power mobility)
Duchene muscular dystrophy (DMD)
Genetic disorder characterized by progressive weakening and degeneration of muscle leading to activity limitations and participation restriction
- Mutation of the dystrophin gene
- Life expectancy is 20-30 years
Typical presentation:
- Clinical signs become apparent at 2-5 years old
- early motor milestones are achieved at expected ages (Difficulty with walking at 6-8 y.o)
- Impairments become more apparent with higher level gross motor activities (difficulty with run ning at 2-6 y.o)
- 8-12 y.o wheelchair dependent
- 12 y.o completely dependent
Progressive muscle weakness and wasting
- Lower limbs>upper limbs
- proximal>distal
- muscles of face, eyes, speech and swallowing and sphincter typically not involved
S & S:
- Waddling gait
- Psudohypertrophy of calves
- Gowers sign
- Toe walking
- Lumbar Hyperlordosis
- Wide stance with ER of LE
PT management
- Avoid aggressive strengthening (esp eccentric contraction)
- Strengtheing and ROM
- Gait training (try to prolong ambulation not fix it)
- Education on overexertion and energy conservation
- Respiratory exercise (breath stacking, assistive cough, and incentive spirometer)
- Transfer training
- Equipment selection (wheelchair, transfer lifts, power mobility)
