Peadiatric Rehabilitation -course-book

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LA TIKA ROY FOUNDATION

2010

Paediatric Rehabilitation Therapy Course

Handbook for interdisciplinary therapy

Nalin Kumar (PT)

Arju Bala (PT)

4 / 3 A , V A S A N T V I H A R E N C L A V E , D E H R A D U N , U T T A R A K H A N D

16- 27 August 2010

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Preface

The course is developed by Latika Roy Foundation, an NGO in Dehradun. The Foundation provides therapy, education, vocational training, counselling, rights based assistance, and of course play time to children with and without special needs. Our projects continue to evolve and touch the lives of individuals, their families, and the community in Dehradun and beyond. As there is a scarcity of interdisciplinary professionals working in the area of child rehabilitation, this course aims to provide skills to therapists (PT, OT, and SLT) in the area of “Paediatric Rehabilitation”.

Aim of the course

“To provide skills to therapists in the area of Paediatric Rehabilitation; to make them well equipped with concepts of child development and to provide them tools for assessment and therapy which are based on evidence based practice and recent advances in the area of paediatric rehabilitation.”

Brief introduction to Latika Roy Foundation

Latika Roy Foundation strives to make Uttarakhand, India, and the entire world a more inclusive place for all people regardless of ability, age, race, creed, or socio-economic background. Aware of the power of individual, we believe that each one of us should have a voice in our community, access to what we need, and respect from those around us. The foundation began working in 1994 as a space that featured arts and crafts, music, dance and sports all under one roof. Inspired by our success over the years, we have grown to a multi-tiered organisation featuring educational programs for babies, children and adults.




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Acknowledgement

The content has been developed with the great help and support of many interdisciplinary professionals working/attached with Latika Roy Foundation. The course content has also been developed with meticulous research from numerous books, journals and online resources. We extend our thanks to all children, family members, staff members, resource persons for their contribution towards the course. Considering the high professional level of the participants in the course we expect this course to be highly interactive and we expect that this will help build the skill levels of all who are related to the course. We offer our gratitude to participants for their participation in the course. Although all contents have been developed with some care and peer-review, chances of error has not been ruled out. We are thankful to the resources available online and this information in used for training purpose only. We would appreciate all feedback about errors or suggestions that would help make future editions of this handbook more robust and factually correct.

Resource Persons 1. Dr. Sebastin Gruschke (MD), Netherlands, Family and Child Physician, Latika

Roy Foundation 2. Dr. Ritu Srivastava (PhD), PhD Psychology, B.Ed. Special Education, Child

counsellor and Clinical Psychologist 3. Dr. Aarti Nair (PT), Clinical Physiotherapist 4. Anne Bruce (SLT), Based in UK, Volunteer and Resource person with Latika

Roy Foundation 5. Barbara Angert (OT), USA, Volunteer and Resource person with Latika Roy

Foundation 6. Pushpa Painuly, Vice Principal and Head of Department Speech and

Language, Karuna Vihar School 7. Dr. Nalin Kumar (PT), Physiotherapist – LRF 8. Dr. Arju Bala (PT), Physiotherapist – LRF 9. Deepak Pandey (B.Tech., PMP), COO - LRF




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Contents

S.No Topic Page No

1 Theory and Principles of child development 6

2 Essential milestones on child development 11

3 Gross Motor Milestones 13

4 Sequence of Postural Development 20

5 II a. Reflexes 22

6 II b. Role of reflex in development 24

7 II c. Contribution of Reflexes 30

8 II d. Development of Grasp 33

9 III. High Risk Infants 35

10 IV. Paediatric Neurological Assessment 38

11 V. Rehabilitation 42

12 VI. ICF

44

13 VII. Goal making in early intervention therapy 45

14 VIII. Sensory Processing Disorder Checklist 47

15 IX. Oromotor Rehabilitation 66

16 X. ADL’s of Children with disability 84

17 Bobath Concept- Techniques of Proprioceptive and Tactile Stimulation

85

18 XI. Neuro Developmental Therapy(NDT) 91

19 XII. Conductive Education 105

20 XIII. Play 106

21 XIV. Biological and Physiological importance of various postures

108




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22 XV. Wooden furniture/equipments used in therapy 109

23 XVI. Do’s and Don’ts in CP 113

24 XVII. Checklist

Chair cum standing frame

115

25 XVIII. Child Development Worksheet 119

26 XIX. Internet Resources 124




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I. Theory and Principles of child development

There are numerous theories on child development.

To understand child development we need to understand the meaning of development. Development means change in functional competence over time. A child’s motor development is an adaptive change towards movement and competence throughout the life span. Competence means skilful mastery of the current skill and transition to the next skill. For a child to learn movement she would need motor control and movement coordination.

Child Development= Nature+ Nurture

Maturation+ Learning= Child Development

Task Individual Environment Performance demands

Anatomical

Opportunity for practice

Movement pattern formation Physiological Encouragement /motivation

Degrees of freedom Biomechanical Instruction Perceptual Environmental

context

Phase/Stage theory views development as a product that: • Progresses from simple to complex • Is sequential and orderly in nature • Builds skill upon skill • Varies in rate from person to person • Requires proficiency in fundamental skills prior to using them as complex skills




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Concluding Concept: Motor Development Is Age-related but Not Age-dependent References

1. David L. Gallahue, Indiana University, USA




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I a. Principles of Development

Development is a continuous process from conception to maturity; for example, for a child who is 7 months old, one has to observe not only whether she can sit, but how she sits, and the degree of maturity she has developed in it.

1. Development depends on maturation and myelination of the nervous system. Until myelination has occurred no amount of practise can make a child learn the relevant skill.

2. Certain primitive reflexes anticipate corresponding voluntary movement and have to be lost before the voluntary movement develops. For example, walking reflex and grasp reflex are present in the newborn period and disappear after some time; reciprocal kick reflex disappears before walking

3. The sequence of development is the same for all children, but the rate of development varies from child to child. e.g. the child has to learn to sit before he can walk, but the age at which children learn to sit and walk varies considerably.

4. Cepahalo- Caudal (head to toe) - Which means the child development follows the sequence from head to toe. First the child learns to control the neck movements and then the child control proceeds to the trunk and later the motor development of legs and toe occurs.

5. Radio- Ulnar (Radius to Ulna)- First the child uses much of the movements of the radial side of the wrist and then proceeds to the Ulnar side. The child learns Radial grasp of objects first and then the Ulnar.

6. Proximal to Distal- The parts which are towards the body’s central line develop first and then the distal part of the body develops i.e, the development of head, trunk and pelvis happens before the development of shoulders, hands, finger and toes.

7. Medio- Lateral- Body parts which are located medial have their development first and then followed by lateral body parts.

8. Gross to fine (Gross movements to precise movements) - Child initially learns gross movements (neck control, sitting, walking) first which precedes the fine movements (grasp, writing, feeding, jumping etc.)

9. Simple to complex- The child learns simple movements and then with practice the child learns the complex tasks. ( Firstly the child learns to hold toy- then pencil- then scribbling lines- then writing alphabets or copying shapes)




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10. Maturation to learning- When the child experiences the movements again and again, the child registers the movements as memory and then is able to utilize it in a learned behaviour.

References:

The Normal Child Development: Ronald S.Illingworth: Chapter-12; The normal course of development




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2. Essential Milestones of Child Development

Stages of Gross & Fine Motor Skill Development:

Age: Gross Motor Skills: Fine Motor Skills:

Month 1 Can lift chin slightly Hands fisted/reflexive grasp

Month 2 Wobbly head while sitting Swipes toys with /hands

Month 3 Holds head steady in sitting

Rolls back to side

Puts weight on arms while on tummy

Hands open

Grasps/holds an object

Hands play at midline

Month 4 Sits on propped arm

Rolls tummy to side

No head lag seen when pulled to sit

Reaches with both arms/hands

Brings fingers/hands in mouth

Squeeze grasp emerging

Month 5 Rolls tummy to back

Wiggles few feet forward

Pushes up with arms while on belly

Sits propped on hands

Reaches with good aim

Month 6 Sits independently for a brief period

Sits in a highchair

Rolls over both ways

Reaches precisely and grasps objects

Transfers toys from hand to hand

Bangs a cup on a table

Month 7 Sits unsupported for ~30 seconds

Rocks on all fours

Pivots in a circle while on tummy

Crosses midline when reaching

Uses whole hand to rake in objects

Thumb to finger grasp emerging

Month 8 Transitions tummy to sit

Crawls forward

Reaches while on tummy

Bangs cubes together

Uses a three-fingered grasp




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Month 9 Transitions sit to tummy

Pulls to stand while holding on

Creeps on all fours

Stands while leaning on furniture

Uses thumb to index finger grasp(crude)

Crude release of objects

Drops toys and objects

Points index finger

Month 10 Cruises along furniture

Stands unsupported briefly

Transfers from crawl to sit

Pokes with fingers

Uses thumb to index finger grasp(precise)

Stacks objects

Month 11 Stands unsupported

Walks with hands held

Releases a cube at will

Removes pegs from a pegboard

Month 12 First independent steps

Stands unsupported~12 seconds

Assumes/maintains kneeling

Puts objects in a container

Releases an object precisely

Stacks two one-inch cubes

12-15 Months Walks independently

Creeps/climbs stairs

Tries to climb out of highchair

Squats to play

Kneels

Stoops and recovers

Throws objects

Places rings on a peg

Holds large crayon in fisted grasp

Pulls large popbeads apart

Builds a 2 block tower

Throws objects

References:

1. Harris County Developmental Inventory, Dr. Sears Baby Book, Hawaii Early Learning Profile

2. The Michigan Developmental Scales




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GROSS MOTOR DEVELOPMENT MILESTONES IN ALL POSTURES

Supine Posture

AGE TONE POSTURE MOVEMENT PATTERN / MUSCLES

REFLEXES USE OF HANDS

1-3 mon

Head, neck & trunk: hypotonicity Limbs: hyper tonicity

Keeps head to one side

Both arms & legs are flexed, knees apart

Sole of feet turn inwards

Keep hands closed (fist), thumb turn in

Large, jerky movements in limbs

Arms more active than limbs

Neck & Head control starts

Movmt. Becomes smooth & cont.

Open hands time to time

Rooting

Suckling

Grasping

Hand opening

Flexor withdrawl

Extensor thrust

Crossed extension

Tonic Lab. supine

Cardinal points

Starts opening hand from time to time

Starts bringing hand from side to midline

3-6 mon

Head: normal

Trunk: slight hypotonic

Limbs: slight hypotonic

Postural stability of shoulder girdle

Raises head to look at feet

Good head holding

Starts counterpoising the limbs in the air

Kicks strongly

Moves legs alternately

Can roll from side to side

Can bridge his hips off the surface (5m)

Tries to sit

Grasp

Moros

Startle

Neck righting

Primitive squeeze

Radial Palmar

Uses hands for grasp

Uses both hands, occasionally one hand

Brings hands together from sides into midline

6-9 mon

Head: normal

Trunk: normal

Limbs:

normal

Posture stability of pelvis

Can lie straight

Can turn his head easily

Child holds a leg up in air in order to grasp his foot with his hand

Supine to side lying

Try to sit from side lying

Rolling & rising sequence of motion

Raking movt.

Startle

Moros

Tilt reaction

Saving reaction

Try to grasp foot by hand

Manipulate toys

Begins to point at object with index finger

Pass toy from hand to hand

Release toys by dropping

9-12 mon

Normal tone Good postural stability:

Head & Neck stability

Shoulder stability

Very active and controlled movements of body & limbs

Pulls himself to sitting from side lying

Landau’s

Pincer

Tilt reaction

Puts hands around bottle when feeding

Try to grasp spoon

Clapping




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Pelvic stability

Turns body to look sideways

Saving reaction Drops & throws objects

Shake toys to make noise

Takes object to mouth less often

12-18 mon

Normal tone Head in center or side (supine position)

Arms/Legs can be flexed or extended when in supine

As child has learnt to sit, stand and walk, he/she no longer prefers supine position

Landau’s

Pincer

Tilt reactions

Saving reactions

Turn pages (thick) of books

Feeds himself with assistance

Likes throwing objects one by one

18-24 mon

Normal tone Lie (supine & prone)

Sit

Stand

Functional sitting and walking

Movements get more refined

Mostly voluntary movements

Landau’s

Can lift objects, throw objects forcefully

Refined grasp and scribbling

2-5 yrs

Normal tone Use supine position to rest and sleep

Use supine position to rest and sleep

Fully functional

Voluntary movements

Further precision – writing & drawing




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Prone Posture



1-2 mon

Limbs: hyper tonicity prevails in flexor muscles.

Head, neck & trunk: hypotonicity prevails / slack / no muscular tone.

Neonate: in prone, the baby promptly turns his head sideways, his cheeks resting on the tabletop. The buttocks are humped up, with the knees flexed under the abdomen. The arms are close to the chest with the elbows fully flexed.

1month - same with hands under the abdomen and arms & legs flexed, elbows away from body, buttocks moderately high.

Reflexive movements. Can flex upper limb and lower limb with greater suppleness.

Limited range, predominantly flexion.

Can raise his head to 45 from the plane of the bed.

0-2month- Gallant’s trunk incurvation.

1-4 months-

a) Cross- extension reflex.

b) Tonic -labyrinthine-prone.

c) STNR

Newborn: the primitive grasp reflex present.

1m. –The reflex is still present.

2m. –The reflex is less apparent and his hands are quite often open.

3-4 mon

Limbs: hypertonicity becoming hypotonicity leading to extension in upper limb and lower limb.

Head and trunk: hypotonicity becoming normal.

Lifts head and upper chest wall up in midline, using forearms to support & (often) actively scratching surface with hands; buttocks flat

Disassociation of head from shoulders; working against gravity

At 4 months: does swimming, flexing and extending all his limbs.

Raises himself on his forearms/ elbows and can raise his head to 45 and 90 from the plane of the bed

Strengthening of neck muscles

1-4 months-

a) Cross- extension reflex.

b) Tonic -labyrinthine-prone.

c) STNR

3mo-2.5 years: Landau’s reflex

‘Grasping on contact’, the child involuntarily grasps an object placed in contact with his hands.

5-6 mon

Limbs: normal tone. Head and trunk: very firm / further increase in tone.

Placed in prone, lifts head and chest wall up supporting himself on flattened palms and extended arms.

Hip-anchoring

Lying on his abdomen, he becomes an aeroplane, supporting his weight on his thorax; he raises his arms and legs.

Rolls from abdomen to his back.

Co-contraction of muscles in upper arm

4-6 months- Righting reactions-Amphibian.


6 month onwards: Tilt reactions

(General rule: Concavity on higher side)

Lying flat on his abdomen, the forearms are hyperextended in front of the infant and his hands flat on the ground. He cannot yet use them to play with but raises himself up on hands.

7-8 mon

Limbs: normal tone. Head and trunk: normal tone.

Placed in prone, lifts head and chest wall up supporting himself on flattened palms and extended arms.

Easily roles over in both directions (back to abdomen and abdomen to back).


Raise one hand from ground to take hold of a cube.

Passes cube from one




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Go from complete flexion in hips to mid-flexion

When lying on his abdomen, he can raise up his entire body on his hands and knees.

6 month onwards: Tilt reaction

7-12 month onwards: Four-point kneeling

Saving reactions

hand to other, bangs them together and on the ground.

Releases objects voluntarily with movmt. of whole hand.

Grasps an object between thumb and little finger.

9-10 mon


Crawling posture – taking weight on hands and knees

Achieves sit from hands and knees: Side sitting, W sitting

Pivots body using limbs to right/left.

The infant tries to crawl on his stomach & progresses to walking on all fours (hands & knees).

He starts by going backwards.


6 month onwards: Tilt reaction

7-12 month onwards: Four-point kneeling

Saving reactions

Grasp objects between base of thumb and fore finger.

Pulls an object by string.

Likes to throw objects.

11-12 mon


Half kneels with hand supports

Rises to upright kneeling with hand supports

Bear-walk posture – weight on hands and feet

Crawls reciprocally

Bear walk – the infant walks more confidently on all fours (hands & feet).


Tilt reaction

4-point kneeling

Saving reactions

Grasp improves further. Can release objects with fine & precise movements.

Points to objects with forefingers.

15 months &above


Kneels unaided or with slight support in prone

Half kneels upright no support (against gravity, extension at the pelvis)

Inclined crawling- climb the stairs on all fours. Smoothly moving from ext/flex to co-contractions.

Knee walks forward


Tilt reaction

4-point kneeling

Saving reactions

Makes towers of 2cubes.

Turn pages of a picture book.




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Sitting Posture



Neonate

Limbs: hyper tonicity

Head, neck & trunk: hypotonicity

Held sitting – back and head uncontrolled

Flexion in total body Grasp reflex

Hand opening

Foot grasp

Head righting

Primitive grasp reflex

2months

Limbs: hypertonicity becoming hypotonicity - extension in upper and lower limb.

Head and trunk: hypotonicity becoming normal.

Held sitting – head remains upright for few moments but wobbles

Head and neck extended but control not present

Back – flexed

Hips – slight ext.

Automatic sitting – protraction of shoulder girdle

Tracking occurs with eye but hand control not present

3months

Head and neck: normal tone

Trunk: Hypotonicity

Limbs: normal tone

Held sitting – head & neck straight.

Back firm but lumbar region still weak

Head control in supine &prone position

Head & Neck – extended to vertical

Lumbar kyphosis present

Increased extension of upper and lower limbs

Labyrinthine head & vestibular righting reflex

Clumsy reaching – bilateral

Grasps objects placed in hand, thumb adducted

4-6

months

Tone is normal in head, neck, trunk &limbs

Postural fixation of head on shoulder girdle

Sitting with support, back straight, legs straight turning out and apart

Sitting on baby chair with back & sides supported or propped on a pillow support

Head & neck -extended/vertical

Hips extended

Legs extended

Sitting lean on both hands, forward with less support

Saving & propping reactions in forward direction

Reaching in all directions

Bilateral to unilateral reach

Thumb pressed in opposition

Ulnar/palmar grasp

Wrist flex./ext.

6-7 months

Tone is normal Postural fixation of trunk on pelvis

Sitting lean on hands

Lift one hand to play with toys

Head, neck – extended

Back – bent to flexion

Arms extended

Hips – flexed, abducted & ext rotated

Saving & propping reactions in forward direction

Manipulate toys with one hand & use other hand for support

Unilateral reach & grasp

Beginning radial grasp




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Knees flexed

7-8 months

Tone is normal Sitting, reach in all directions; hand support sideways

Trunk – more control so rotation is possible

Upper limb – all movements, ext. in one arm, flex in other

Lower limb –

Rotation in hip

Saving & propping reactions in sideways direction

Use hands to save in forward and side directions

Pats images of face in mirror

8-9 months

Tone is normal Sitting without external support, may use hand for support

Head, neck, trunk & upper limb – variety of motions

Lower limb – control improved

Full ext. of hip still not possible

Tilt reactions in forward, sideways & backward directions


Manipulation with both hands (bilateral & unilateral)

9-12 months

Tone is normal Turn to play, reach, no self hand support

Sitting to various positions – round sitting, long sitting, side sitting, W sitting, cross legged, stool/chair sitting

Co-contraction of neck & trunk

Trunk/Pelvic disassociation

Hips - anchoring is complete; wt. shifting. rotation

Rising out of sitting and getting into all sitting positions

Tilt reactions in forward, sideways & backward directions


Point with index finger

Reach and grasp in all directions

Pick & place objects in & out of large container

1-5 years

Tone is normal Various postures can be attained Various muscle activities can be performed because of better control & coordination

Saving reactions completely developed

Hand manipulation is refined




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Upright Posture



0-3 months

Head, neck & trunk: hypotonic

Limbs: Flexor tone in lower limbs, extensor tone developing in knees

Trunk supported – Plantigrade feet

Hip slight flexion

Knee extension

Ankle neutral

No pelvic stability

Flexor withdrawl

Crossed extension

Placing reaction

Automatic walk

No hand function

3-6 months

Head: normal


Limbs: slight hypotonic

Bears some weight

Trunk support is required

Hip extension

Knee hyper ext.

Ankle – plantar flex.

Simultaneous contraction of opposing muscle groups started (co-contraction)

Positive supporting (3m)

Negative supporting (3-5m)

Foot grasp

Uses hands for grasp

Uses both hands, occasionally one hand

Brings hands together from sides into midline

6-9 months

Head: normal


Limbs:

normal

Stands with forearm leaning and pelvis support

When standing by holding- hips may flex, feet are flat

Hips – both flexors and extensors contract simultaneously (co-cont)

Toes flexion

Placing reaction more predominant

Saving reaction

Use hands as support while standing

In saving, use hands for protection

9-12 months

Normal tone Pulls self to stand

Cruises using two hands

Stands, holds one hand & can reach in all directions with other

Can lift one leg

Reciprocal contraction of opposite muscle

Abduction & adduction of hips while cruising

Saving reaction Counterpoising

Saving

Both arms for holding

Support & bear weight for cruising

12-18 months

Normal tone Stands, stoops and recovers

Stands without support

Extension of hip, knee, ankle (neutral) while standing

Contraction of hip extensors of one limb & flexors of other limb while standing (1 limb)

Simultaneous contract. of

Tilt reaction – trunk

Staggering – forwards, sideways, backwards

Counterpoising without holding

Walking – hand for support, 2 hand to 1 hand hold

Carry objects while walking

Use hand for rising

Support while stair




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Sequence of Postural Development

Propping- This is first posture that the child assumes in all fundamental postures. It is basically a preparation stage for the child to have an experience in the posture. So it means the child needs to experience propping in all the postures.

Head Free- After propping the child starts using his head neck to learn from the environment. The ability of the child to assume head control and perform the neck movements is said as Head free. The child needs to perform head free movements in all the postures as part of typical development.

flex/ext

Abd/flex/ext of hip while staggering

climbing

18-24 months

Normal tone Stand alone, runs

Turns (pivots)

Co-contraction of flex/ext

Reciprocal leg function while running (dissociation)

Rotation of hip & trunk while turning

Reciprocal limb movmt. while climbing

Normal Use hands freely for manipulating

One hand support for climbing

Can use hands for playing while walking or standing

2-3 yrs

Normal tone Running

Climbing stairs

More refined jumping

Symmetrical contraction & relaxation of both limbs while jumping

Limb dissociation – reciprocal movmt. of limbs

Normal No support required

Use hands simultaneously for manipulation

Play-catches ball

3-4 yrs

Normal tone Stands on preferred leg, 5-10secs

Heel to toe stand

Extension of preferred leg

Flexion of leg

Dorsiflexion – neutral - plantarflexion

Hyperextension in trunk

Flex./Add. Of upper limb

Normal Play

More refined counterpoising

4-5 yrs

Normal tone Balance on one leg (10sec)

Walks on narrow line

Extension and adduction of hip

Counterpoising

Normal Play

More refined counterpoising




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Weight Shift- Slowly as the child starts learning about the environment he starts weight shifting.

Saving- With further integration, the child learns to save himself (first forwards and then laterally). With experiences of unequal weight bearing the child learns to save self and slowly he develops the saving.

Hands free- As the child experiences Saving and weight shifts this helps in the development of muscle tone, strength and slowly the child learns to lift one hand, slowly progress to both hands and then to in hand manipulation. The ability to use bilateral hand movements in a coordinated way is said as hands free.

Tilt/Counter poising- Once both hands are free, there is further increase in pelvic stability with dissociation of the body in segments. This enables the child to tilt without changing the base of support when pushed suddenly. The body resists the change in COG (as in saving) by tilting.

Legs free- After tilting the child now develops dissociation of lower limbs with enables the child in transition of posture and to move in further higher postures.

Pivoting- Dissociation with increasing stability helps in rolling and pivoting.

Moving out of posture- As now the Development has completed from head to toe, the child will now move on to further higher posture.

Note= The sequence of development is same in all children and in all the postures. The child needs to complete the sequence before moving to higher posture. However this might always be not true, a child in a higher posture may also have some missing links present.




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II a. Reflexes

Reflex is a specific automatic involuntary response to a specific stimulus to the body. It is controlled by the spinal cord without the involvement of the CNS.

1. Local static reaction- These stiffens the body weight against gravity.

2. Segmental static reaction- Involves more than one body segment and includes the flexor withdrawal reflex, extensor thrust reflex and the crossed extensor reflex.

3. General static reaction (attitudinal reflexes)- These involves changes in position of the whole body in response to changes in head position. These reflexes include the ATNR,STNR and TLR

4. Righting reaction- These allow us to assume or resume a specific orientation of the body in space and in relationship to the head and ground. There are 5 types of righting reactions-

a) Optical righting reaction which contributes to the reflex orientation of the head using visual inputs.

b) Labyrinthine righting reaction which orients the head to an upright vertical position in response to vestibular signals.

c) Cubed on-head righting reaction which orients the head in response to proprioceptive and tactile signals from the body in contact with a supporting surface. Landau reaction is an example of all 3 reactions mentioned above.

d) Neck on body righting reaction orients the body in response to cervical afferents which report changes in the position of the head neck to forms of this reflex have been reported log rolling(immature form) and segmental rolling (mature form).

e) Body on body righting reaction- Keeps the body oriented with respect to the ground, regardless of the position of the head.

5. Balance and protective reaction- These emerge in association with a sequentially organised series of equilibrium reactions. These are of 3 types:-

a) Tilt reaction are used for controlling the center of gravity to a tilting surface

b) Postural fixation reaction (saving reaction) - Are used to recover from forces applied to the other parts of the body.

c) Parachute or protective responses- Protect the body from injury during a fall.




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II b. Role of reflexes in development

S.No Reflex Normal until

Stimulus Response Contribution

1. Sucking 3 mon Introduce finger into mouth

Sucking action of lips and jaw Development of oral muscles, tongue placement, swallowing and gag reflex.

2. Rooting 3 mon Touch baby cheeks Head turn towards stimulus Develops opening of mouth.Helps in localisation of breast.

3. Cardinal points

2 mon a)Touch corner of mouth

b)center of upper lip stimulated

c)Center of bottom lip is stroked.

a) Bottom lip lowers on same side and tongue moves towards point of stimulation. When fingers slide away, the head turns to follow.

b) Lip elevates, tongue moves towards place stimulated. If finger slides along oronasal groove then head extends.

c) Lip is lowered and tongue is directed to site of stimulation. If finger moves towards chin, the mandible is lowered and chin flexed.

Helps to locate nipple. Develops lateralisation of tongue.

4. Grasp 3 Mon Press finger on Ulnar side of palm

Fingers flex and grip objects (head in midline during rest)

Development of flexor tone on hand and upper extremities.

5. Hand opening

1 mon Stroke Ulnar border of palm and little finger

Automatic opening of the hand. The baby learns extension movement of finger

6. Foot grasp 9 mon Press sole of foot behind the toes

Grasping response of feet Helps baby to grasp the surface when held in standing

7. Placing Remains Bring the anterior aspect of foot or hand against the edge of table.

Child lifts limbs up to step onto table. Helps to place foot in the appropriate position for standing and locomotion. Ability to place the hand and upper extremity in a position for support in sitting and quadruped position.

8. Primary walking

2 mon Hold baby upright and tip forwards, sole of foot press against table.

Initiates reciprocal flexion and extension of legs.

It indicates the potential for automatic reciprocal walking.




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9. Galant’s trunk incuvation

2 mon Stroke back lateral to the spine.

Flexion of trunk towards the side of stimulus.

Initiates unilateral trunk mobility.

Creates asymmetrical pattern of movement. Initial movement for rotation initiates amphibian movement necessary for creeping, crawling breaks up symmetrical pattern of movement.

10. Automatic Sitting

2 mon Pressure id placed on the thighs and the head is held in flexion, supine position.

Child pulls to sitting from supine Weight bearing in development of standing.

11. Moro 0-6 months Baby supine and back of head is supported above table, drop head backwards, associated with loud noise.

Abduction and extension of arms. Hands open. This phase is followed by adduction of arms as if in embrace.

Develops extensor tone bilaterally in upper extremities and fingers. As this reflex matures and integrates the upper extremities are prepared for propping and parachute reaction.

12. Startle Remains Obtained by sudden loud noise or tapping the sternum

Elbow is flexed (not extended as in Moro) and hand remains closed.

Helps as protective function.

13. Landau 3 months to 2 ½ years, strong 10 months

Child held in ventral suspension, head lift

The head,spine and legs extended. Extended arms and shoulders.

Develops extensor tone in the neck musculature of the neck to the trunk to the hips, knees, ankles and feet.

A precursor to good trunk extension for straight sitting.

Develops the balance of flexors and extensors for stable sitting, especially of the hip musculature.

14. Flexor withdrawal

2 months Supine; head mid line;legs extended- stimulates sole of foot

Uncontrolled flexion response of stimulates leg(do not confuse with response to tickling)

Helps in protective reaction.

Helps to develop between flexor and extensor tone.

15. Extensor thrust

2 months Supine; head mid position, one leg extended opposite leg flexed-turn head to

Uncontrolled extension of stimulated leg (do not confuse with response of tickling)

Helps in extensor tone in legs.




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one side

16. Crossed extension

3 months Supine, head , mid position, legs extended stimulate medial surface of one leg by tapping

Opposite leg adducts, extends, internally rotates, foot planter flexes (typically scissor position).

Develops alternative extensor tone in the lower extremities breaks up symmetrical flexion and extension movement, precursor to amphibian movement in preparation for creeping and crawling and walking pattern

17. ATNR 6 Months

Usually pathological

Baby supine, head in mid line, arms and legs extended- turn head to one side

Extension of arm and leg on face side, or increase in flexor tone.

Breaks symmetrical flexion/extension pattern of movement. Enables each side of body separately.

18. STNR Rare and usually pathological

1) Baby is quadruped position or over tester’s knees- ventroflex the head.

2)Position as above dorsiflex the head

Arms flex or flexor tone dominates.

An arm extendes or extensor tone dominates; legs flex or flexor tone dominates.

Helps in creating a balance between flexor and extensors for stable position against gravity.

Helps in developing prone on elbows to extended elbows to 4 foot quadruped to reciprocal crawling

19. Tonic Labyrinthine supine

Pathological Baby supine, head in mid position; arms and leg extended, test stimulus is the position.

Extensor tone predominates when the arms and legs are passively flexed

Develops extensor tone throughout body.

Creates ability to reach.

Brings limbs to mid line, cross midline.

Free limbs for function away from body, reach, spatial orientation and direction.

20. Tonic Labyrinthine prone

3 months Baby prone; head in mid position.Test stimulus- prone postion.

Unable to dorsifles head, retract shoulders, extend trunk, arms, legs.

Stimulation of flexor tone of the total body, helps to counter balance the extensor tone in supine.

This gives stability to proceed prone development.

21. Positive supporting

3 months Hold baby in standing position press down the soles of feet

Increase of extension in legs, planter flexion, genu recurvatum may occur.

Helps to develop co-contraction of flexor and extensor necessary for standing.

22. Negative supporting

3-5 months Hold in weight bearing position

Baby ‘sinks’ ataxia Allows the child for voluntary weight bearing.




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23. Neck righting

5 months Supine, rotate head to one side, actively or passively

Body rotates in same direction as the head.

It initiates rolling(Log rolling)

24. Associated reaction

pathological Have baby squeeze an object(with involved side)

Clench of other hand or increase of tone in other parts of body. Abnormal overflow.




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Righting Reactions

S.No Reaction Emerges at Stimulus Response Contributions

1. Amphibian 4-6 Months Baby in prone, head in mid position, legs extended, lifts pelvis on one side.

Automotive flexion outward of hip and knee on same side.

Initiates to attain quadruped position and crawling.

2. Body righting reaction

6- 10 Months If the child rotates hip and knee (on arm on head actively)

Active segmental reaction.

Dissociation of head and limb occurs which helps in crawling, walking etc.

3. Body righting derotative

4 -6 Months Baby in supine rotate head( on one side) Knee on one side

Active derotation at waist is segmental rotation of trunk between shoulders and pelvis.

1) Segmental contraction f trunk, neck, hip & leg muscles.

2) Dissociation of trunk and limb helps in crawling and later walking.

4. Labyrinthine head righting vestibular righting

2-6

Months

1) Hold the baby blindfolded in prone in supine, as head drops.

2) Hold the baby blindfolded in supine, in space, as head drops.

3) Hold the baby blindfolded, hold around pelvis and tilt it to one side.

Head raises to normal position, face vertical mouth horizontal.

Head raises to normal position, face vertical mouth horizontal.

Head rights itself to normal position, face vertical mouth horizontal.

These reactions help to attain antigravity position.

5. Optical righting 6 Months Hold baby either in supine (or in prone, in space as head drops)

Head raises t normal position face vertical mouth horizontal.

Helps to attain antigravity posture.




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Equilibrium Reaction

S.No Reaction Emerges at Stimulus Response Contribute

1. Tilt Reactions

Supine and Prone

6 Months Baby on tilt board, arms and legs extended, tilt the board on one side.

Lateral curving of head and thorax, parachute reaction in limbs accompany trunk rotation.

All the equilibrium reactions are protective. They facilitate the body to maintain various body postures external force and balance in dynamic postures.

2. Four point kneeling 7-12 months Child in Quadruped position

a) Tilt towards one side.

b) Tilt forwards.

c)Tilt backwards

a) Lateral curving of head and thorax.

Abduction extension of arms and legs on raised side and protective reactions on lowered side may accompany this.

b) Forward head and back flexed. Backward-head and back extended.

Do-

3. Sitting 9-12 months Baby seated n chair

a)Tilt the child to one side

b) Tilt the child forward.

c) Tilt the child backward.

a)

Head and thorax curve, abduction-extension of arms and legs on raised side and protective reactions on lowered side may accompany this.

Child extends head and back.

Child flexes head and back.

Do-

4. Kneel standing 18 months Child in kneel sitting position.

Tilt to one side

Head and thorax curve, abduction- extension of arm and leg on raised side, other protective reaction may accompany this.

Do-

5. Standing 12-18 months

Child in standing position

a)Tilt sideways

a) Head and thorax curve abduction extension of arms and leg on raised side, other protective reactions may accompany this.

b)Tilt forwards

c) Tilt Backwards

Do-




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II c. Contribution of Reflexes

1. Gallant’s Trunk Incurvation Stimulus: Stroke back, lateral to the spine. Response: Flexion of trunk towards side of trunk

Contribution:

Initiates unilateral trunk mobility.

Creates asymmetrical pattern of movement.

Initial movement for rotation.

Initiates amphibian movement necessary for creeping, crawling.

2. Cross Extension Reflex Stimulus: Head mid-position, legs extended, stimulate medial surface of one leg by tapping Response: Opposite leg adducts, extends, internally rotates and foot plantar flexes Contribution:

Develops alternating extensor tone in the lower extremities

Breaks up symmetrical flexion and extension movements

Precursor to amphibian movement in preparation for creeping, crawling and walking patterns

Enables crossing midline

Combines with the positive supporting reflex in the early stages to supply sufficient extensor tone to stand on one lower limb while the opposite limb flexes

3. Cross Tonic Labyrinthine Reflex Stimulus: Head mid-position, stimulus is the prone position Response: Unable to dorsiflex head, retracts shoulders, extends trunk, arms and legs Contribution:

Stimulation of flexor tone of total body

Counterbalance extensor tone developing in supine position

Balance is maintained; this gives the stability that is necessary for prone development to proceed to higher levels

4. Symmetrical Tonic Neck Reflex (STNR) Stimulus: Quadruped position, ventroflex the head Response: Arms flex (increase in flexor tone) & legs extend (increase in extensor tone) Contribution:

Helps in creating a balance between flexors and extensors for stable position against gravity

Helps in developing prone-on-elbows to extended elbows to 4 foot quadruped to reciprocal crawling

5. Landau Reaction




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Stimulus: Child head in ventral suspension, lift head; depress head Response: Head, spine and legs extend, extend arms at shoulder; Hip, knees and elbows flex Contribution:

Develops extensor tone in the neck musculature of the neck, to the trunk to the hips, knees, ankles and feet

A precursor to good trunk extension for straight sitting

Develops the balance of flexors and extensors for stable sitting, especially of the hip musculature

6. Righting Reaction (Amphibian) Stimulus: Head mid-position, legs extended, lift pelvis on one side Response: Automatic flexion outward of hip and knee on same side Contribution:

With other reflexes act as a precursor to creeping

7. Tilt Reaction (Prone) Stimulus: Lying in prone position on the tilt board, arms and legs extended, tilt board to one side Response: Lateral curving to head and thorax, protective reaction in limbs accompany trunk reaction Contribution:

Enables movement of trunk to maintain balance

8. Four-point kneeling Stimulus: Quadruped position, tilt board towards one side; tilt forward and backward Response: Lateral curving of head and thorax, abduction-extension of arm and leg on raised side, protective reaction on lower side; Forward – head and back flex, Backward – head and back extend Contribution:

Maintain balance and equilibrium

9. Placing

Stimulus: Infant held up; dorsum of hand/foot brushed against edge of table Response: Lifts (flexes) hand/foot and places it on the table/surface Contribution:

Ability to place the foot in appropriate position for standing and locomotion

Initiates flexion/extension pattern for walking 10. Saving Stimulus: Sudden tip sideways/backwards Response: Hands extend for balance / counterpoising Contribution:

Development of trunk muscle tone

Helps in attaining postural fixation (head on trunk & trunk on pelvis) and lateral

sideways control

11. Positive/Negative Support (Upright posture) Stimulus: Weight bearing




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Response: Plantar flexion, hyperextension at knee and extension at hip (pillar like lower limb – Positive) Sudden sinking (Negative) Contribution:

Precursor to standing and walking through the development of extensor tone in the lower extremities and to a lesser degree in hips and trunk

12. Automatic walking (Upright posture) Stimulus: Stimulate sole of feet Response: Walking pattern, scissoring walk Contribution:

Indicates potential for automatic, reciprocal walking

Develops flexor & extensor tone balance for future standing & walking

Dorsiflexion of foot and extension on toes

References: Sheridan, Mary D., From birth to five years, Published in 1997 by Routledge Gassier, A guide to the phycho-motor development of the child, Fiorentino, Mary R., A basis for sensorimotor development – Normal and Abnormal, Published by Charles C. Thomas Levitt, Sophie, Treatment of Cerebral Palsy and Motor Delay, 3rd Edition, Published in 2000 by Blackwell Science Ltd.




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II d. GRASP Grasp is defined as the attainment of an object by hand. It is an important milestone by which the child starts using its hands. Contribution of reflexes in development of grasp: 1) Palmer grasp reflex (Birth to 3 months)

Stimulus- tactile stimulus to the palmer side of hand. Response- Mass finger flexion with adduction of the thumb. (formation of fist) Contribution- It helps in the development of sustained holding.

2) Avoidance reaction (From neonatal period to 12 months) Stimulus- Tactile stimulation of the dorsal aspect of the hand and fingers, ulnar

border of hand and palmer surface of the fingers. Response- Withdrawal of the hand and palmer surface of the fingers. Contribution- Initiates releasing of objects.

3) Traction reflex (from birth to 5 months) Stimulus- Passive abduction of shoulder. Response- Flexion pattern throughout the upper limb. Contribution-It helps in development of brief holding.

4) Imitative grasp reaction- Stimulus- Tactile stimulation of either radial or ulnar side of hand. Response- Supination at wrist. Contribution- Helps in developing proper positioning of hand to grasp a desired

object.




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Development of Grasp: S. no Month Type of Grasp Pattern 1. At birth Thumb is adducted in the palm and fingers are flexed. 2. Up to 1 month On stroking ulnar side of palm and little finger the

hand opens reflexively. 3. 2 months Thumbs are adducted 4. 0-3 months Grasp reflex- Reflexively fingers are flexed. 5. 3 months Traction response and grasp reflex absent. 6. 3-4 months Ulnar palmar grasp- Child holds the object with little

and ring finger against the palm without the use f thumb.

7. 4-5 months Palmer grasp- Grasps the objects against the palm without the use of thumb. (Primitive Squeeze)

8. 5-6 months Radial Palmer grasp- Holds the object with his thumb, index and middle finger against the palm.

9. 6-8 months Raking grasp- The child can pick up small beads by flexing the fingers towards the palm without using the thumb. Can transfer from one hand to another(7 Months onwards)

10. 8 months Superior palmer grasp- Grasps an object with finger and base of thumb( Initial stage of thumb opposition)

11. 9 months Radial digital grasp- Grasps the object with the thumb index and middle fingers without using the palm.

12. 10 months Inferior Pincer(Pre- Pincer) Grasp- grasps an object with his thumb and index finger; Extend finger- The child extends the wrist while grasping in order to facilitate the function of finger flexors.

13. 11-12 months Superior Neat Pincer grasp- Can preciously grasps a tiny object with thumb and index finger opposition.

14. 12-18 months Pronated and Supinated grasp- Can hold a cylindrical object ( Marker pen) in the palm with flexion of the fingers and thumb.

15. 3-4 years Tripod Grasp- Can hold a pencil precisely between the tips of index, middle finger and thumb (By opposition between thumb and the fingers).




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III. High Risk Infants: The term high-risk infants refer to those infants whose peri-natal medical course might contribute to motor, cognitive or social deficits. Risk factors are defined as the characteristics or circumstances of a person or group that are associated with increased risk of having, developing or being specially adversely affected by a morbid process. Risk factors may have a single effect or a combination of effects for particular outcomes. Tjossem’s categories of Biological, Established and Social risk provide a framework for categorizing indicators for neonatal therapy referral.

Biological Risk: It refers to neurodevelopmental risk due to medical or physiological conditions in the prenatal, perinatal or neonatal period. Biological risks include placental abnormalities, labour/ delivery complications, prenatal infection, and teratogenic factors.

Biological Risk:

Birth weight of 1500 g or less. Gestational age of 32 weeks or less. Small for gestational age (less than 10th percentile for weight). Prenatal exposure to drugs or alcohol. Ventilator requirement for 36 hours or more. Intracranial haemorrhage: grade III. Periventricular leukomalacia. Muscle tone abnormalities (hypotonia, hypertonia, asymmetry of tone/ movement). Recurrent neonatal seizures (3 or more). Feeding dysfunction. Symptomatic TORCH infections (Toxoplasmosis, Rubella, Cytomegalovirus infection, Herpes

virus type II infection. Meningitis. Asphyxia with Apgar score less than 4 at 5 minutes. Multiple birth

Established Risk: Established risk is the risk for neurodevelopmental deficits associated with a diagnosis that is clearly established in the neonatal period.

Hydrocephalus Microcephaly Chromosomal abnormalities Musculoskeletal abnormalities (congenital dislocated hips, limb deficiencies, arthrogryposis) Brachial plexus injuries (Erb’s palsy, Klumpke’s paralysis)

Environmental/ Social Risk: It involves developmental risk related to competency in parenting roles and factors in family dynamics. Such risks may be heightened by prolonged




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hospitalization of infants with sub optimal levels of stimulation and interaction in the intensive care nursery environment, inadequate infant- parent attachment.

Behavioral state abnormalities (lethargy, excessive irritability, behavioral state liability).




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Levels of risk

III Severe

Severe respiratory distress requiring mechanical ventilation Intracranial hemorrhage Gestational age between 26 to 30 weeks Small for gestational age, with a birth weight of less than 1750 grams Persistent atypical patterns of neurological behavior Congenital infections

II Moderate

Birth weight of less than 1750 grams Hyperbilirubinemia Congenital heart disease Respiratory distress without mechanical ventilation Post- maturity

I Mild

Birth weight of 1750-2500 grams




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II. Paediatric Neurological Assessment

Assessment

Child developmental assessment needs an understanding of various areas of child development like- Gross and fine motor, Social emotional, speech and language, cognitive development, vision and hearing. All assessment procedures should focus:-

S- Subjective

O- Objective

A- Assessment

P-Procedure

While we reach towards Short Term Goals we need to do repeated reassessments to monitor the child’s progress.

Initial Detailed assessment- Setting goal and activities- Working on goals- Re assessment- New goal making or working on goals – assessment

This is a continuous phase of the assessment procedure as mentioned above. While assessing the child we need to know that we might not be able to complete all the assessments in a single day, the complete child’s assessment could take few days, in these cases often we have to rely on the information from the parents as they are considered a reliable resource.

At times parents have difficulty in understanding the outcomes of the therapy program. In these cases an initial assessment video should be taken and after 2-3 months we can take another video. This would help therapists to provide a strong support for their interventions and the resultant outcome.

Observation Observation begins before making any physical contact and from enough of a distance to encompass the infant as a whole.

Behavioral indicators of stress and stability

Signs of stability or approach signals Smooth respiration Pink, stable color Animated facial expression Brightening of the eyes Cooing Smiling Hand to mouth activity Well-regulated muscle tone Smooth body movements, minimal movement




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Signs of Stress Physiological Indicators:

Color changes Cyanosis Change in respiratory rate and rhythm Change in heart rate Coughing Sneezing Yawning Vomiting Hiccup

Motor Indicators:

Sudden change in muscle tone Flaccidity (truncal, extremities, facial) Stiffness

1. Ophisthotonos 2. Finger splaying

Alterations in the quality of movement Disorganized movement Jitteriness

Behavioural Indicators: Irritability (crying, inconsolability) Staring Gaze aversion Hyper alertness Sleeplessness and restlessness

ANTHROPOMETRIC MEASUREMENTS The head and chest circumference and the length of the infant are measured and recorded.

Head circumference:

Head circumference is a useful measure of intracranial volume and helps in assessment of brain development by measuring the growth of the brain.

Head circumference is measured at the maximum skull circumference. Measure should be taken using a flexible tape. Tape should be moved around, to ensure that this is the largest circumference for the particular infant being measured.




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Measure the occipito-frontal head circumference, at its maximum and ensure that it falls within the normal range (31-38 cm at term).

The brain grows to 80% of its adult volume during the first 2 years of life so many neurological diseases that occur early in life will impact the growth of the brain.

A small head (Microcephaly) or a large head (Macrocephaly or Hydrocephalus) can be key findings in explaining the neurological abnormalities of a child.

Weight: A standing scale can be used by having an adult hold the infant and weighing the infant and adult together. The adult is then weighed alone and the adult’s weight is subtracted from the total. Weight should be measured again to ensure accuracy. If the two weights differ, a third weight should be taken and so on until two results agree.

During the first 3 days after birth, infants normally lose upto 10 to 15 percent of their body weight

Length: With infants under age 2 years, recumbent length is measured as a substitute for height.

The recommended procedure is to use a measuring table with movable perpendicular head and footboards and two persons to help hold the infant. One person places the supine infant’s head against the headboard. The other person straightens the infant’s hips and knees, places the footboard against the sole of infant’s foot and read the length measure.

A second alternative method is to stretch a tape measure beside or under the properly positioned infant and read the length directly from the tape.

PALPATION:

Feel the anterior fontanelle for its tension. Fullness may indicate raised intracranial pressure (cerebral edema, hydrocephalus or meningitis). The posterior fontanelle is also often open at this age.

Inspection of the inside of the mouth is best done either while the baby is crying or by making him open it. One should ensure that the palate is intact.




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III. Rehabilitation

To restore to useful life, as through therapy and education or to restore to good condition, operation, or capacity is called Rehabilitation.

WHO states the rehabilitation of persons with disability as:-

Rehabilitation of people with disabilities is a process aimed at enabling them to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels. Rehabilitation provides disabled people with the tools they need to attain independence and self-determination.

Professionals involved in Rehabilitation are:-

1. Physicians, Surgeons, Doctors

2. PT, OT, SLT, PRO

3. Special Educators, Nurses, Dietician, Counsellor, Psychologist, Dance and drama therapists, art therapist

4. Para professionals

5. Lawyers and policy makers

Broadly classifying the professionals into 3 sectors

1. Medical Rehabilitation (Doctors and therapists) 2. Educational or adaptive life rehab (Teachers and skills training professionals) 3. Social rehabilitation (By policy makers and para-professionals)

Child Rehabilitation

Medical Rehabilitation

Adaptive living/ educational Rehabilitation

Social

Rehabilitation




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Need to understand Rehabilitation

1. The Status of children with disabilities

Around 10% of the world's population, or 650 million people, live with a disability. They are the world's largest minority.

20% of the world's poorest people are disabled, and tend to be regarded in their own communities as the most disadvantaged.

80% of persons with disabilities live in developing countries Between 120 and 150 million disabled children and young people live in the world. Less than 10 % of these children attend school. The global literacy rate for adults with disabilities is as low as 3 % and 1% for

women with disabilities. 30% of street youths are disabled. Violence against children with disabilities occurs at annual rates at least 1.7 times

greater than for their non-disabled peers. For every child killed during armed conflicts, three are injured and permanently

disabled. Comparative studies on disability legislation shows that only 45 countries have anti-

discrimination and other disability-specific acts.

Sources: UNICEF, UNDP, World Bank, CRIN.

Indian scenario on Disability

The Indian Census 2001 reports that 21.9 million persons in the Indian total population (2.13%) are disabled, and that 1.67% of the total population within the age-group 0-19 years (7 million) are living with disability. This data includes persons with visual, hearing, speech, physical and mental impairments. The data from studies by WHO and other international health organizations indicates much higher numbers, more towards 5-6 %.

Of all persons with disability, 35.9% are in the 0-19 age-group. One in every 10 children is born with, or acquires, a physical, mental or sensory disability. 75% of the disabilities are preventable. Only 1% of children with disability have access to education. Hardly 50% of disabled children reach adulthood, and no more than 20% survive to cross the

fourth decade of life.

With this much of burden on the health care system and more number of children adding up every day, we do not have so many rehabilitation professionals to provide Rehabilitation to the children and persons with disability in India.

IV. ICF (International Classification of Functioning, disability and health)

The International Classification of Functioning, Disability and Health, known more commonly as ICF, is a classification of health and health-related domains. These domains are classified from body,




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individual and societal perspectives by means of two lists: a list of body functions and structure, and a list of domains of activity and participation. Since an individual’s functioning and disability occurs in a context, the ICF also includes a list of environmental factors.

The ICF is WHO's framework for measuring health and disability at both individual and population levels. The ICF was officially endorsed by all 191 WHO Member States in the Fifty-fourth World Health Assembly on 22 May 2001(resolution WHA 54.21). Unlike its predecessor, which was endorsed for field trail purposes only, the ICF was endorsed for use in Member States as the international standard to describe and measure health and disability.

The ICF puts the notions of ‘health’ and ‘disability’ in a new light. It acknowledges that every human being can experience a decrement in health and thereby experience some degree of disability. Disability is not something that only happens to a minority of humanity. The ICF thus ‘mainstreams’ the experience of disability and recognises it as a universal human experience. By shifting the focus from cause to impact it places all health conditions on an equal footing allowing them to be compared using a common metric – the ruler of health and disability. Furthermore ICF takes into account the social aspects of disability and does not see disability only as a 'medical' or 'biological' dysfunction. By including Contextual Factors, in which environmental factors are listed ICF allows to records the impact of the environment on the person's functioning.

Source- http://www.who.int/classifications/icf/en/


http://www.who.int/classifications/icf/en/



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V. Goal Making in Early Intervention Therapy

Goal making in therapy is a more crucial part then planning the therapy sessions, as it is not one persons view about the goal, but we should also know about the parent’s opinion on goal making as if what in their view is important.

A child's earliest years are filled with new stimulations and novel experiences that drive his or her cognitive, social, and physical growth. The first 3 years of life are a critical time for brain development, especially if a child is delayed or restricted in development. If a child needs support to develop optimally, rehabilitation therapy can help.

Early intervention is a collection of therapy and support services provided to children from birth to 3 years old who have disabilities, or who are at risk for developing them. Early Intervention provides the help they need to succeed later in life.

The goals of early intervention should be SMART:-

S- Subjective/specific

M- Measureable

A- Achievable

R- Realistic

T- Time frame

The goals made in Paediatric Rehabilitation are of 2 types:-

1. Long term Goal (LTG) (6Mo-1year)- It is usually advisable to make goals like a higher level posture. In case this is not possible to attain a higher posture, our goal should be to maintain the posture and work on any other related issues like (fine motor, cognitive, sensory etc.) and prevent regression.

2. Short Term Goal (STG) (3-6month) - These goals help us to reach our Long term goal and keep track of the progress of child towards the same.

Further to reach to the short term and long term goals we need to find out the activities or therapies which would help us in reaching our target. These developmental activities help to facilitate the growth and development of the child and focus on the home program that the parents can do at home.

Example: For achieving a Short Term Goal of bilateral midline hand movements of a child the activities could be:-

1. Playing with a ball 2. Playing clap clap 3. Asking the child to bring a Doll or toy that is fairly big enough that the child needs both hands

to hold the object 4. Providing opportunities to the child to use his reasoning as how will he utilise his abilities to

use both hands




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5. Finally the parents need to teach on the importance of mid line orientation as to how it is helping us in daily life and how would the child be benefited in near future.

For children with developmental delays or a known physical or mental condition associated with a high probability of delays, therapy can help improve their motor, cognitive and sensory processing along with communication, and play skills. The goal is to enhance development, minimize the potential for developmental delay, and help families to meet the special needs of their infants and toddlers.

Based on the family's values and priorities, it outlines what parents want their child to learn to do. Next, the coordinator and parents determine what kind of expertise might be most useful to achieve the outcomes. Therapy may be the only service or one of several services identified through the IFSP (Individual Functional Screening Profile) process as best able to help the child reach his or her goals.

Paediatric therapy services should be tailored to the child’s family, including siblings and other family members, and services should be altered and adapted as the family’s needs change.




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VI. Sensory Processing Disorder Checklist: Signs and Symptoms Of Dysfunction

The purpose of this sensory processing disorder checklist is to help parents and professionals who interact with children become educated about particular signs of sensory processing dysfunction.

Disclaimer: This checklist is not to be used as the absolute diagnostic criteria for labelling children with sensory processing disorder.

Please understand the "Five Caveats" that Carol Stock Kranowitz points out in her book, "The Out-Of-Sync Child" (1995), about using a checklist such as this. She writes: 1. "The child with sensory dysfunction does not necessarily exhibit every characteristic. Thus, the child with vestibular dysfunction may have poor balance but good muscle tone."

2. "Sometimes the child will show characteristics of a dysfunction one day but not the next. For instance, the child with proprioceptive problems may trip over every bump in the pavement on Friday yet score every soccer goal on Saturday. Inconsistency is a hallmark of every neurological dysfunction. " 3. "The child may exhibit characteristics of a particular dysfunction yet not have that dysfunction. For example, the child who typically withdraws from being touched may seem to be hypersensitive to tactile stimulation but may, instead, have an emotional problem." 4. "The child may be both hypersensitive and hyposensitive. For instance, the child may be extremely sensitive to light touch, jerking away from a soft pat on the shoulder, while being rather indifferent to the deep pain of an inoculation." 5. "Everyone has some sensory integration problems now and then, because no one is well regulated all the time. All kinds of stimuli can temporarily disrupt normal functioning of the brain, either by overloading it with, or by depriving it of, sensory stimulation."




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Tactile Sense: input from the skin receptors about touch, pressure, temperature, pain, and movement of the hairs on the skin.

Signs of Tactile Dysfunction

1. Hypersensitivity to Touch (Tactile Defensiveness)

__ becomes fearful, anxious or aggressive with light or unexpected touch __ as an infant, did/does not like to be held or cuddled; may arch back, cry, and pull away __ distressed when diaper is being, or needs to be, changed __ appears fearful of, or avoids standing in close proximity to other people or peers (especially in lines) __ becomes frightened when touched from behind or by someone/something they can not see (such as under a blanket) __ complains about having hair brushed; may be very picky about using a particular brush __ bothered by rough bed sheets (i.e., if old and "bumpy") __ avoids group situations for fear of the unexpected touch __ resists friendly or affectionate touch from anyone besides parents or siblings (and sometimes them too!) __ dislikes kisses, will "wipe off" place where kissed __ prefers hugs __ a raindrop, water from the shower, or wind blowing on the skin may feel like torture and produce adverse and avoidance reactions __ may overreact to minor cuts, scrapes, and or bug bites __ avoids touching certain textures of material (blankets, rugs, stuffed animals) __ refuses to wear new or stiff clothes, clothes with rough textures, turtlenecks, jeans, hats, or belts, etc. __ avoids using hands for play __ avoids/dislikes/aversive to "messy play", i.e., sand, mud, water, glue, glitter, play dough, slime, shaving cream/funny foam etc. __ will be distressed by dirty hands and want to wipe or wash them frequently __ excessively ticklish




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__ distressed by seams in socks and may refuse to wear them __ distressed by clothes rubbing on skin; may want to wear shorts and short sleeves year round, toddlers may prefer to be naked and pull diapers and clothes off constantly __ or, may want to wear long sleeve shirts and long pants year round to avoid having skin exposed __ distressed about having face washed __ distressed about having hair, toenails, or fingernails cut __ resists brushing teeth and is extremely fearful of the dentist __ is a picky eater, only eating certain tastes and textures; mixed textures tend to be avoided as well as hot or cold foods; resists trying new foods __ may refuse to walk barefoot on grass or sand __ may walk on toes only

2. Hyposensitivity To Touch (Under-Responsive):

__ may crave touch, needs to touch everything and everyone __ is not aware of being touched/bumped unless done with extreme force or intensity __ is not bothered by injuries, like cuts and bruises, and shows no distress with shots (may even say they love getting shots!) __ may not be aware that hands or face are dirty or feel his/her nose running __ may be self-abusive; pinching, biting, or banging his own head __ mouths objects excessively __ frequently hurts other children or pets while playing __ repeatedly touches surfaces or objects that are soothing (i.e., blanket) __ seeks out surfaces and textures that provide strong tactile feedback __ thoroughly enjoys and seeks out messy play __ craves vibrating or strong sensory input __ has a preference and craving for excessively spicy, sweet, sour, or salty foods

3. Poor Tactile Perception And Discrimination:




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__ has difficulty with fine motor tasks such as buttoning, zipping, and fastening clothes __ may not be able to identify which part of their body was touched if they were not looking __ may be afraid of the dark __ may be a messy dresser; looks disheveled, does not notice pants are twisted, shirt is half un tucked, shoes are untied, one pant leg is up and one is down, etc. __ has difficulty using scissors, crayons, or silverware __ continues to mouth objects to explore them even after age two __ has difficulty figuring out physical characteristics of objects; shape, size, texture, temperature, weight, etc. __ may not be able to identify objects by feel, uses vision to help; such as, reaching into backpack or desk to retrieve an item




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Vestibular Sense: input from the inner ear about equilibrium, gravitational changes, movement experiences, and position in space.

Signs of Vestibular Dysfunction

1. Hypersensitivity to Movement (Over-Responsive):

__ avoids/dislikes playground equipment; i.e., swings, ladders, slides, or merry-go-rounds __ prefers sedentary tasks, moves slowly and cautiously, avoids taking risks, and may appear "wimpy" __ avoids/dislikes elevators and escalators; may prefer sitting while they are on them or, actually get motion sickness from them __ may physically cling to an adult they trust __ may appear terrified of falling even when there is no real risk of it __ afraid of heights, even the height of a curb or step __ fearful of feet leaving the ground __ fearful of going up or down stairs or walking on uneven surfaces __ afraid of being tipped upside down, sideways or backwards; will strongly resist getting hair washed over the sink __ startles if someone else moves them; i.e., pushing his/her chair closer to the table __ as an infant, may never have liked baby swings or jumpers __ may be fearful of, and have difficulty riding a bike, jumping, hopping, or balancing on one foot (especially if eyes are closed) __ may have disliked being placed on stomach as an infant __ loses balance easily and may appear clumsy __ fearful of activities which require good balance __ avoids rapid or rotating movements

2. Hyposensitivity to Movement (Under-Responsive):




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__ in constant motion, can't seem to sit still __ craves fast, spinning, and/or intense movement experiences __ loves being tossed in the air __ could spin for hours and never appear to be dizzy __ loves the fast, intense, and/or scary rides at amusement parks __ always jumping on furniture, trampolines, spinning in a swivel chair, or getting into upside down positions __ loves to swing as high as possible and for long periods of time __ is a "thrill-seeker"; dangerous at times __ always running, jumping, hopping etc. instead of walking __ rocks body, shakes leg, or head while sitting __ likes sudden or quick movements, such as, going over a big bump in the car or on a bike

3. Poor Muscle Tone And/Or Coordination:

__ has a limp, "floppy" body __ frequently slumps, lies down, and/or leans head on hand or arm while working at his/her desk __ difficulty simultaneously lifting head, arms, and legs off the floor while lying on stomach ("superman" position) __ often sits in a "W sit" position on the floor to stabilize body __ fatigues easily! __ compensates for "looseness" by grasping objects tightly __ difficulty turning doorknobs, handles, opening and closing items __ difficulty catching him/her self if falling __ difficulty getting dressed and doing fasteners, zippers, and buttons __ may have never crawled as an baby __ has poor body awareness; bumps into things, knocks things over, trips, and/or appears clumsy __ poor gross motor skills; jumping, catching a ball, jumping jacks, climbing a ladder etc.




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__ poor fine motor skills; difficulty using "tools", such as pencils, silverware, combs, scissors etc. __ may appear ambidextrous, frequently switching hands for coloring, cutting, writing etc.; does not have an established hand preference/dominance by 4 or 5 years old __ has difficulty licking an ice cream cone __ seems to be unsure about how to move body during movement, for example, stepping over something __ difficulty learning exercise or dance steps




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Proprioceptive Sense: input from the muscles and joints about body position, weight, pressure, stretch, movement, and changes in position in space.

Signs Of Proprioceptive Dysfunction

1. Sensory Seeking Behaviors:

__ seeks out jumping, bumping, and crashing activities __ stomps feet when walking __ kicks his/her feet on floor or chair while sitting at desk/table __ bites or sucks on fingers and/or frequently cracks his/her knuckles __ loves to be tightly wrapped in many or weighted blankets, especially at bedtime __ prefers clothes (and belts, hoods, shoelaces) to be as tight as possible __ loves/seeks out "squishing" activities __ enjoys bear hugs __ excessive banging on/with toys and objects __ loves "roughhousing" and tackling/wrestling games __ frequently falls on floor intentionally __ would jump on a trampoline for hours on end __ grinds his/her teeth throughout the day __ loves pushing/pulling/dragging objects __ loves jumping off furniture or from high places __ frequently hits, bumps or pushes other children __ chews on pens, straws, shirt sleeves etc.

2. Difficulty with "Grading Of Movement":

__ misjudges how much to flex and extend muscles during tasks/activities (i.e., putting arms into sleeves or climbing) __ difficulty regulating pressure when writing/drawing; may be too light to see or so hard the tip of writing utensil breaks




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__ written work is messy and he/she often rips the paper when erasing __ always seems to be breaking objects and toys __ misjudges the weight of an object, such as a glass of juice, picking it up with too much force sending it flying or spilling, or with too little force and complaining about objects being too heavy __ may not understand the idea of "heavy" or "light"; would not be able to hold two objects and tell you which weighs more __ seems to do everything with too much force; i.e., walking, slamming doors, pressing things too hard, slamming objects down __ plays with animals with too much force, often hurting them




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Signs of Auditory Dysfunction: (no diagnosed hearing problem)

1. Hypersensitivity To Sounds (Auditory Defensiveness):

__ distracted by sounds not normally noticed by others; i.e., humming of lights or refrigerators, fans, heaters, or clocks ticking

__ fearful of the sound of a flushing toilet (especially in public bathrooms), vacuum, hairdryer, squeaky shoes, or a dog barking

__ started with or distracted by loud or unexpected sounds

__ bothered/distracted by background environmental sounds; i.e., lawn mowing or outside construction

__ frequently asks people to be quiet; i.e., stop making noise, talking, or singing

__ runs away, cries, and/or covers ears with loud or unexpected sounds

__ may refuse to go to movie theaters, parades, skating rinks, musical concerts etc.

__ may decide whether they like certain people by the sound of their voice

2. Hyposensitivity to Sounds (Under-Registers):

__ often does not respond to verbal cues or to name being called

__ appears to "make noise for noise's sake"

__ loves excessively loud music or TV

__ seems to have difficulty understanding or remembering what was said

__ appears oblivious to certain sounds

__ appears confused about where a sound is coming from

__ talks self through a task, often out loud

__ had little or no vocalizing or babbling as an infant

__ needs directions repeated often, or will say, "What?" frequently




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Oral Dysfunction

1. Hypersensitivity to Oral Input (Oral Defensiveness):

__ picky eater, often with extreme food preferences; i.e., limited repertoire of foods, picky about brands, resistive to trying new foods or restaurants, and may not eat at other people's houses)

__ may only eat "soft" or pureed foods past 24 months of age

__ may gag with textured foods

__ has difficulty with sucking, chewing, and swallowing; may choke or have a fear of choking

__ resists/refuses/extremely fearful of going to the dentist or having dental work done

__ may only eat hot or cold foods

__ refuses to lick envelopes, stamps, or stickers because of their taste

__ dislikes or complains about toothpaste and mouthwash

__ avoids seasoned, spicy, sweet, sour or salty foods; prefers bland foods

2. Hyposensitivity To Oral Input (Under-Registers)

__ may lick, taste, or chew on inedible objects

__ prefers foods with intense flavor; i.e., excessively spicy, sweet, sour, or salty

__ excessive drooling past the teething stage

__ frequently chews on hair, shirt, or fingers

__ constantly putting objects in mouth past the toddler years

__ acts as if all foods taste the same

__ can never get enough condiments or seasonings on his/her food

__ loves vibrating toothbrushes and even trips to the dentist

Signs Of Olfactory Dysfunction (Smells):




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1. Hypersensitivity To Smells (Over-Responsive):

__ reacts negatively to, or dislikes smells which do not usually bother, or get noticed, by other people

__ tells other people (or talks about) how bad or funny they smell

__ refuses to eat certain foods because of their smell

__ offended and/or nauseated by bathroom odors or personal hygiene smells

__ bothered/irritated by smell of perfume or cologne

__ bothered by household or cooking smells

__ may refuse to play at someone's house because of the way it smells

__ decides whether he/she likes someone or some place by the way it smells

2. Hyposensitivity To Smells (Under-Responsive):

__ has difficulty discriminating unpleasant odors

__ may drink or eat things that are poisonous because they do not notice the noxious smell

__ unable to identify smells from scratch 'n sniff stickers

__ does not notice odors that others usually complain about

__ fails to notice or ignores unpleasant odors

__ makes excessive use of smelling when introduced to objects, people, or places

__ uses smell to interact with objects




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Signs Of Visual Input Dysfunction (No Diagnosed Visual Deficit):

1. Hypersensitivity to Visual Input (Over-Responsiveness)

__ sensitive to bright lights; will squint, cover eyes, cry and/or get headaches from the light

__ has difficulty keeping eyes focused on task/activity he/she is working on for an appropriate amount of time

__ easily distracted by other visual stimuli in the room; i.e., movement, decorations, toys, windows, doorways etc.

__ has difficulty in bright colorful rooms or a dimly lit room

__ rubs his/her eyes, has watery eyes or gets headaches after reading or watching TV

__ avoids eye contact

__ enjoys playing in the dark

2. Hyposensitivity To Visual Input (Under-Responsive Or Difficulty With Tracking, Discrimination, Or Perception):

__ has difficulty telling the difference between similar printed letters or figures; i.e., p & q, b & d, + and x, or square and rectangle

__ has a hard time seeing the "big picture"; i.e., focuses on the details or patterns within the picture

__ has difficulty locating items among other items; i.e., papers on a desk, clothes in a drawer, items on a grocery shelf, or toys in a bin/toy box

__ often loses place when copying from a book or the chalkboard

__ difficulty controlling eye movement to track and follow moving objects

__ has difficulty telling the difference between different colors, shapes, and sizes

__ often loses his/her place while reading or doing math problems

__ makes reversals in words or letters when copying, or reads words backwards; i.e., "was" for "saw" and "no" for "on" after first grade

__ complains about "seeing double"

__ difficulty finding differences in pictures, words, symbols, or objects




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__ difficulty with consistent spacing and size of letters during writing and/or lining up numbers in math problems

__ difficulty with jigsaw puzzles, copying shapes, and/or cutting/tracing along a line

__ tends to write at a slant (up or down hill) on a page

__ confuses left and right

__ fatigues easily with schoolwork

__ difficulty judging spatial relationships in the environment; i.e., bumps into objects/people or missteps on curbs and stairs




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Auditory-Language Processing Dysfunction:

__ unable to locate the source of a sound

__ difficulty identifying people's voices

__ difficulty discriminating between sounds/words; i.e., "dare" and "dear"

__ difficulty filtering out other sounds while trying to pay attention to one person talking

__ bothered by loud, sudden, metallic, or high-pitched sounds

__ difficulty attending to, understanding, and remembering what is said or read; often asks for directions to be repeated and may only be able to understand or follow two sequential directions at a time

__ looks at others to/for reassurance before answering

__ difficulty putting ideas into words (written or verbal)

__ often talks out of turn or "off topic"

__ if not understood, has difficulty re-phrasing; may get frustrated, angry, and give up

__ difficulty reading, especially out loud (may also be dyslexic)

__ difficulty articulating and speaking clearly

__ ability to speak often improves after intense movement




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Social, Emotional, Play, And Self-Regulation Dysfunction:

Social:

__ difficulty getting along with peers

__ prefers playing by self with objects or toys rather than with people

__ does not interact reciprocally with peers or adults; hard to have a "meaningful" two-way conversation

__ self-abusive or abusive to others

__ others have a hard time interpreting child's cues, needs, or emotions

__ does not seek out connections with familiar people

Emotional:

__ difficulty accepting changes in routine (to the point of tantrums)

__ gets easily frustrated

__ often impulsive

__ functions best in small group or individually

__ variable and quickly changing moods; prone to outbursts and tantrums

__ prefers to play on the outside, away from groups, or just be an observer

__ avoids eye contact

__ difficulty appropriately making needs known

Play:

__ difficulty with imitative play (over 10 months)

__ wanders aimlessly without purposeful play or exploration (over 15 months)

__ needs adult guidance to play, difficulty playing independently (over 18 months)

__ participates in repetitive play for hours; i.e., lining up toys cars, blocks, watching one movie over and over etc.




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Self-Regulation:

__ excessive irritability, fussiness or colic as an infant

__ can't calm or soothe self through pacifier, comfort object, or caregiver

__ can't go from sleeping to awake without distress

__ requires excessive help from caregiver to fall asleep; i.e., rubbing back or head, rocking, long walks, or car rides

Internal Regulation (The Interoceptive Sense):

__ becoming too hot or too cold sooner than others in the same environments; may not appear to ever get cold/hot, may not be able to maintain body temperature effectively

__ difficulty in extreme temperatures or going from one extreme to another (i.e., winter, summer, going from air conditioning to outside heat, a heated house to the cold outside)

__ respiration that is too fast, too slow, or cannot switch from one to the other easily as the body demands an appropriate respiratory response

__ heart rate that speeds up or slows down too fast or too slow based on the demands imposed on it

__ respiration and heart rate that takes longer than what is expected to slow down during or after exertion or fear

__ severe/several mood swings throughout the day (angry to happy in short periods of time, perhaps without visible cause)

__ unpredictable state of arousal or inability to control arousal level (hyper to lethargic, quickly, vacillating between the two; over stimulated to under stimulated, within hours or days, depending on activity and setting, etc.)

__ frequent constipation or diarrhea, or mixed during the same day or over a few days

__ difficulty with potty training; does not seem to know when he/she has to go (i.e., cannot feel the necessary sensation that bowel or bladder are full

__ unable to regulate thirst; always thirsty, never thirsty, or oscillates back and forth

__ unable to regulate hunger; eats all the time, won't eat at all, unable to feel full/hungry

__ unable to regulate appetite; has little to no appetite and/or will be "starving" one minute then full two bites later, then back to hungry again (prone to eating disorders and/or failure to thrive)

Ref: http://www.sensory-processing-disorder.com/sensory-integration-dysfunction-symptoms.html


http://www.sensory-processing-disorder.com/sensory-integration-dysfunction-



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VII. Oro-Motor Rehabilitation

• Feeding : Process including gathering of &preparation for intake of food, sucking or chewing & swallowing

• Deglutition: Semiautomatic motor action of muscles of respiratory & GIT that propels food

from oral cavity to stomach. (Miller 1986)

Typical Development of Feeding Skills (0 to 3 years old)

Newborn to 1 Month • Takes 2-4 ounces of liquid per feeding; 6 or more feedings per day

• Uses a suckling or sucking pattern; loses some liquid

• Swallows with suckle-swallow pattern; tongue may protrude slightly through lips with extension/retraction movement (suckle reflex and tongue thrust reflex)

• Sequences two or more sucks before pausing to swallow

3 months-4 months

• Takes 4-7 ounces of liquid; 4-6 feedings per day

• Sequences 20 or more sucks; swallowing follows sucking with no discernable pauses when hungry; good coordination of suck/swallow/breathe sequence.

• 4 months: loss of sucking reflex; sucking becomes an intentional act; loss of tongue thrust reflex—increases ability to accept spoon-fed cereal or smooth puree.

5 to 6 months • Cereals and pureed foods; liquids • Takes 9 to 10 ounces of food or liquid per feeding; 4-6 feeding per day




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• Uses primitive phasic bite-release pattern on soft cookie; biting rhythm is regular with no

controlled, sustained bite; may revert to sucking cookie instead of biting • May use intermittent up/down chewing movements 7 to 8 months • Thicker pureed foods at 7 months; ground or junior foods and mashed table foods at 8 months • Visually or tactilely recognizes spoon; jaw quiets and remains in stable, open position until spoon

enters mouth; tongue relaxes to accept spoon. • Long sequences of sucking, swallowing, and breathing. With cup drinking may have continuous

sucks followed by uncoordinated swallowing (much liquid lost). Larger mouthfuls by cup may result in coughing or choking.

• Tongue moves up and down in a munching pattern; tongue shows more lateralization with a gross rolling movement or simple horizontal shift when food is placed on the side biting surfaces.

9 to 12 months • Longer sequences of continuous sucks with cup drinking; still has difficulty coordinating sucking,

swallowing, and breathing with cup drinking. • Can hold a soft cookie between teeth without biting all the way through (graded bite); may

alternate this holding pattern with phasic bite pattern. • Vertical jaw movements in chewing with variations in up/down movement and speed. Uses

diagonal rotary movements as the tongue moves from the center of the mouth to the side for chewing.

• Uses lateral tongue movements when food is placed on side of mouth; begins to transfer food from center of tongue to side.

• 10 months: lips move to remove food from spoon. • Independent finger feeding 12 to 14 months • liquids and ground, mashed, or coarsely chopped table foods (including easily chewed meats) • uses a controlled bite on soft cookie; may not be able to sustain bite on hard cookie and may

revert to phasic bite or sucking • can transfer food laterally from center of mouth to biting surfaces • lips are active during chewing; may lose food or saliva during chewing; uses upper teeth or gums

to clean lower lip as it is drawn inward. • swallows liquid from cup with sucking movement; may lose some liquid; swallowing following

sucking with no pause. Some coughing may occur is liquid is flowing too quickly. 15 to 18 months • 15 months: phasic bite reflex no longer present; uses a controlled, sustained bite; may pull head

backward in slight extension to help with bite. • 18 months: given liquids and coarsely chopped table foods (including most meats and raw

vegetables) • Can chew with lips closed (inconsistent)—lips are closed for chewing primarily when needed to

prevent food from falling out • Swallows solid food with easy lip closure and no loss of food or saliva • Upper lip is closed on cup for better seal for drinking; swallowing follows sucking with no pause;

well coordinated pattern. • Diagonal rotary chewing movements




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• Upper and lower lips active during chewing and cleaning 19 to 21 months • Uses controlled, sustained bite; opens mouth wider than necessary to bite foods of various

thicknesses.




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24 months • Swallows liquid from cup with easy lip closure; no loss of liquid • Swallows solid foods (including combination of texture) with easy lip closure; no loss of food • Can transfer food from either side of mouth to other side without pausing in center • Can internally stabilize cup without biting on edge of cup • Able to grade opening of jaw when biting foods of different thicknesses • Chewing movements mixture of vertical and rotary movements 24 to 36 months • Eats the same food as the rest of the family! • *chewing with a grinding movement does not usually occur until approximately 48 months Red flags for feeding and swallowing problems in young children include: • arching or stiffening of the body during feeding • irritability or lack of alertness during feeding • failure to accept different textures of food • prolonged feeding times (more than 30 minutes) • excessive drooling or leaking food/liquid from mouth • gurgly, hoarse, or breathy voice quality • coughing, gagging, or throwing up during meals or after meals • recurring pneumonia or respiratory infections • difficulty coordinating breathing with eating or drinking • frequent spitting up • less than normal weight gain or growth • pocketing food in the mouth for prolonged period of time Mechanism of Swallowing: Swallowing occurs in three stages:

1. Oral transit, (here defined as including oral prep) the tongue cups to position the food/fluid/saliva for swallowing, and the front of the tongue elevates, followed by elevation of the back of the tongue.

2. Pharyngeal transit: The food is propelled into the pharyngeal esophageal (P-E) segment,

which is the beginning of the second stage of swallowing. The epiglottis comes down to protect the trachea as the hyoid bone elevates (carrying the thyroid cartilage and larynx upward) and then immediately returns to the pre-swallow position.

3. Esophageal transit: begins, with a peristaltic wave that propels the bolus down the

esophagus into the stomach. Three types of pressure variations impact the bolus and the control of the swallowing process. These include the positive and negative pressures associated with the muscular forces of the mouth, pharynx and esophagus; the filling and emptying of the bolus in the tract; and the pressures of respiration, including sub-glottic pressure variations. Normal swallowing includes primitive and mature patterns. * In the primitive pattern, the person is able to complete only one suck/swallow sequence per breath.




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* In the mature pattern, the person can complete two or more swallows per breath (consecutive swallowing). Essential Components of Swallowing: Normal Jaw Patterns The following normal jaw patterns are presented from less to more controlled. In normal development, these patterns do not develop linearly. In the same person, more mature patterns may be observed with easy to chew foods, (ex: a cookie) and more primitive patterns may be observed with harder to chew items (ex: steak). The primitive patterns do not disappear. More mature patterns are used with foods requiring grinding, while more primitive patterns are used with less viscous foods. Close and hold - Jaw stability and strength are adequate to close around the item with normal muscle tone, but not yet strong enough to allow up and down jaw movement around the item. Do not confuse this normal pattern with tonic bite. Wide jaw excursion - This early pattern is characterized by poor jaw grading in which downward jaw displacement is exaggerated, but not associated with abnormal tone. It is associated with poor internal jaw stability. It may occur during suckling, sucking and chewing. It is often seen during nursing, and then again when cup drinking is introduced. As the jaw gains greater internal stability, better control of jaw movement occurs with improved grading and wide jaw excursions decrease. Phasic biting - This primitive normal jaw pattern is characterized by rapid rhythmical up and down movement of the jaw. No lateral movement of the jaw is seen. It may occur following stimulation of cheek, gums, or molars. It is usually limited in power. Nonstereotypic vertical movements - In this beginning chewing pattern, the jaw moves up and down with easy contact and release. Only vertical movement has developed, so that only food coming between the teeth is broken up. Munching - This early chewing pattern combines phasic biting and some nonstereotypic vertical movements of the jaw with tongue movement to the hard palate. No lateral jaw movement is observed with these five patterns. A person with these patterns would not be able to grind up fibrous foods. Soft, lumpy foods and ground meats are usually the diet tolerated with these patterns. Lateral jaw shift - This is a lateral (side to side) movement of the jaw with no downward displacement of the jaw. Diagonal movement - This is a lateral, downward movement of the jaw to either side with easy contact and release. It aids in the placement of food between molars for chewing. There is no grinding movement, and no movement of the jaw across midline. It occurs in conjunction with vertical jaw movement. Diagonal rotary movement - There is a lateral, downward movement with upward, horizontal sliding movements for grinding foods between molars. The jaw moves to one side or the other, without crossing midline. It may accompany lateral movement of food from the center of the tongue to the teeth. Circular rotary movement - This is the most mature chewing pattern, with jaw movement laterally, downward, across the midline to the other side and upward to close. It may occur either clockwise or counter -clockwise. It may accompany transfer of food from one side of the mouth across the midline to the other side of the




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mouth. Each of these normal patterns may be accompanied by significant muscle weakness. The pattern is observed, but is not efficient for more viscous foods due to lack of power for closing the jaw. Abnormal jaw patterns interfere with eating, drinking and speech. Controlled movement of the cheeks, lips and tongue is also adversely affected by these abnormal jaw patterns. Sometimes the patterns are interpreted by the caregiver as volitional, resulting in an inappropriate response by the caregiver. When these patterns are present, mealtimes take longer. There will be poor control of items placed in the mouth with loss of foods, fluids, medications and saliva. Oral hygiene becomes more challenging to provide, often resulting in poor oral hygiene and resulting in gum problems, plaque build up, tooth decay and loss of teeth. Appropriate handling techniques for mealtime and oral hygiene are needed.




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Abnormal Jaw Movements: Jaw clonus - Rapid, rhythmical movement of the jaw upon closure, indicating weakness or fatigue. May be observed in infants during sucking. Tonic bite reflex - This is jaw closure accomplished by forceful, sustained upward movement of the mandible. It occurs following stimulation of the teeth or gums. It is accompanied by increased abnormal tone in the jaw muscles. It is difficult to release. Damage to the teeth or to the object placed in the mouth may occur. The tonic bite increases if the item is pulled on. Do not confuse this pattern with a bite reflex which results in closing or approximation of closing following stimulation to the lips, gums or teeth. This normal reflex becomes integrated before age two, and is not associated with abnormally increased muscle tone. Jaw thrust - The jaw opens through forceful, sustained downward and outward movement of the jaw (mandible). It occurs following presentation of foods for biting. It may also occur as part of a total body extension pattern. It is accompanied by increased abnormal tone in jaw muscles. Do not confuse this pattern with wide jaw excursions (poor jaw grading), often seen in normal infants. Pressing up on jaw increases the jaw thrust. Jaw retraction - There is a forceful, sustained movement of the lower jaw, carrying it up and toward the back so that the alignment of the molars is displaced. It is associated with an abnormal increase in jaw muscle tone. It may occur following change in body position, or following the presentation of foods, liquids, or medications into the mouth. It may also occur in conjunction with abnormal muscle tone and abnormal patterns of movement. There is less room in the back of the mouth, so swallowing and breathing are more difficult. Dystonic jaw movement - An abnormal pattern characterized by rhythmical, nonfunctional movement of the jaw associated with Parkinson's or Parkinson's like symptoms. The ability to interrupt the movement is related to the severity of the disease. With less severe involvement, the pattern can be interrupted during functional activities, such as eating and speech, and will not be observed during sleep. Bruxism - Bruxism or toothgrinding, may occur for a variety of reasons. In individuals with abnormal oral motor patterns, bruxism may be associated with muscle weakness or with abnormally increased muscle tone. Pressure to the outside of the face is not effective in reducing bruxism. Emphasize on increased internal jaw stability with increased opportunities for closing the molars around chewy objects has been helpful in reducing the incidence of bruxism. Bruxism may increase when an ear infection or fluid in the middle ear occurs. It may also increase with headaches or when there is pain due to gum or tooth disease. Normal Lip Patterns Three normal lip patterns are lip rounding, lip spreading, and lip closure. Lip rounding - The lips form a circular shape maintaining muscular tonal balance. This position is attained through easy, nonforceful movement. The amount of rounding can be varied as needed to obtain and maintain a seal around a feeding utensil, or to build up or maintain intra-oral pressure.




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Lip spreading - The lips form an expanded horizontal line from the rest position, maintaining normal muscle tone. The position is attained through easy, non-forceful movement. The amount of spreading can be varied as needed to control substances in the front of the mouth, or to aid in drawing substances into the mouth. Lip closure - The lips meet and touch to seal off the contents of the mouth from the outside. The position is attained through easy, non-forceful movement. The amount of contact and the area of contact can be varied as needed to retain substances in the mouth. Note: Each of these patterns may be reduced in efficiency by weakness of the lip muscles. For example, the lips may close, but food/fluid escapes due to weak lip seal. Abnormal Lip Patterns In addition to recognizing normal patterns, you should also evaluate for abnormal patterns, including lip retraction, and lip purse-string, hypotonicity and asymmetrical lip movement. Each of these patterns interferes with lip closure, mouth opening and with forming a seal around a feeding utensil (bottle, straw, cup, spoon, etc.). It also affects one's ability to obtain and/or maintain intra-oral pressure. Lip tremor - Rapid, small movements of the lips during purposeful activity, such as lip seal. A mildly abnormal pattern indicating fatigue. Lip retraction - This is an abnormal pattern in which increased abnormal tone pulls the corners of the lips up and back. It may be observed to affect upper lip movement more than lower lip movement. The person with this pattern may be described as "always smiling". The anterior cheek area usually shows a retracted pattern also. Lip purse-string - This is an abnormal pattern in which the corners of the lips are pulled back as the rest of the lip pulls to midline, with an increase in abnormal tone. Increased tone may extend from below the nose to the chin and into the cheeks. Asymmetrical lip movement - This is an abnormal pattern in which one side of the lip moves with less control than the other side. Abnormal patterns and muscle tone are noted on the affected side. Hypotonic lips - This is an abnormal pattern in which the lips appear flaccid, with little or no active movement. The lips may look puffy. The lower lip may appear more involved than the upper lip. Dystonic lip movement - An abnormal pattern characterized by rhythmical, nonfunctional movement of either or both lips, associated with Parkinson's or Parkinson's like symptoms. The ability to interrupt the movement is related to the severity of the disease. With less severe involvement, the pattern can be interrupted during functional activities such as eating and speech, and will not be observed during sleep. Lip Fasciculations - An abnormal pattern of nonrhythmical, unorganized contraction of individual muscle fibers across the lips. May be observed when the lips are at rest, or following direct stimulation of the lips. May also be observed during generalized hypotonicity affecting the whole body.

Abnormal swallowing patterns include: * No active swallowing - No discernible upward movement of cartilage and larynx. Substance appears to flow back through use of gravity. Head and neck may be hyperextended.




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* Incoordination of suck/swallow/breathing - Person breathes while food/fluids are in the pharyngeal-esophageal segment, or the bolus moves into the airway during the swallow, resulting in coughing and possible aspiration into the lungs. Normal Tongue Patterns Tongue movements are an integral part of the eating process. The following six normal patterns (suckling, simple tongue protrusion, sucking, munching, tongue tip elevation and lateral tongue movements) are presented in order from primitive to more mature patterns. Suckling - The primary movement in suckling is extension – retraction. The tongue does not extend beyond the lips. Lateral movement is not observed. The tongue may show a semi-bowl shape (cupping). The tongue remains flat and thin. The movement is accomplished with normal tonal changes with rhythmical cycles of extension - retraction. Jaw opening and closing occur in conjunction with tongue movement. This is a normal but primitive pattern. Simple tongue protrusion - This is a primitive, normal movement associated with the suckling pattern. The tongue extends between the teeth or gums. The tongue remains flat and thin with no abnormal tonal changes. (In the normal population, this may be called tongue thrust, especially by speech pathologists.) Sucking - The tongue is flat and thin, movement is up and down and is contained within the mouth. The tongue tip elevates to the anterior hard palate. The movement is rhythmical, up-down cycles, with normal tonal changes. This is the primary pattern for adults. The normal rhythm for nutritive sucking is one cycle per second; non-nutritive suck is faster or slower than that rate. A suck occurs with two kinds of pressure: positive pressure and negative pressure. Positive pressure occurs when the jaw elevates, the tongue elevates to the hard palate, and the lips seal. Negative pressure occurs when the jaw drops, the tongue moves away from the hard palate, the posterior cheeks contract, the soft palate elevates, and the lips remained sealed. More coordination is needed for the negative phase of suck. Tongue tip elevation - This pattern emerges during suck. The anterior one-third of tongue raises upward to contact the upper teeth or alveolar ridge (gums behind upper teeth). It indicates separation of tongue and jaw movement. This movement continues to develop so that the tongue tip can reach the upper lip, even when the jaw is depressed. Munching - The primary movement of the tongue is up and down with flattening and spreading. Lateral tongue movements are not observed during this pattern. Tongue movements are accompanied by up and down movement of the jaw for chewing and biting. This is a normal tongue pattern observed in early chewing. Food is positioned on the body of the tongue and raised upward to the palate to break up the food prior to swallowing. Soft, lumpy foods, ground meats, and foods that dissolve in saliva (such as crackers), are tolerated with this chewing pattern. All of these patterns are normal, but do not involve any lateral tongue movement. The person cannot move food between molars for chewing. Since this is needed for chewing more viscous foods, s/he fails to move along the continuum of greater variety and separation of tongue, lip, and jaw patterns. The person is limited to a diet which does not require chewing and grinding, such as a pureed diet. The final tongue movements to consider are: Lateral tongue movements - The tongue moves to either side, horizontally, to shift food from the center of the mouth to the side. Initially, the tongue may barely shift toward the gum. As skill develops, the tongue will contact the gum or molars. With more control, the tongue will move over the gums or molars. With continued development, the tongue will extend into either cheek. As skills develop, the tongue can move food from one side across the midline to the other side. As movements become more defined, lateral and tongue tip elevations are combined to allow sweeping/cleaning movements of lips, palate, and inside




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the cheeks. This allows particles of food to be gathered and positioned on the tongue prior to swallowing. Abnormal Tongue Patterns Tongue tremor - Rapid, small movements of the tongue during purposeful activity, such as sucking. A mildly abnormal pattern indicating fatigue. May be observe in nursing infants during sucking. Exaggerated tongue protrusion - The tongue shows extension (forward movement) beyond the border of the lips which is non-forceful. The movement is a rhythmical extension-retraction pattern. It is similar to a suckle pattern, but is mildly abnormal. Tongue thrust - The tongue is thickened and bunched. The movement is an outward extension beyond the border of the lips. The movement is forceful, and is associated with an abnormal increase in muscle tone. This may occur as part of a total extension pattern of the body, or with hyperextension of the head and neck. The tongue thrust may make it difficult to insert a utensil into the mouth or may cause food to be ejected during feeding. During drinking, the tongue may thrust into the cup or may protrude in a very tight, bunched fashion beneath the cup. Tongue retraction - In this abnormal movement, the tongue appears thickened and bunched. The movement is retraction, a strong, pulling back of the tongue into the posterior portion of the oral cavity, associated with abnormal increased muscle tone. The tip of the tongue is not forward and even with the lower lip. It is pulled back toward the middle of the hard palate and may be held firmly against the hard or soft palate. Hard approximation of the tongue with the palate may make insertion of utensils extremely difficult and may make it nearly impossible for any food to be placed on top of the tongue for swallowing. Gagging may be increased for the person with this pattern. Severe tongue retraction can partially block the laryngeal airway contributing to added respiratory problems during feeding. Tongue retraction may be associated with other patterns of retraction or extension in the body (i.e., shoulder retraction or neck extension) or it may be an abnormal pattern used as compensation by a person with poor swallowing patterns. When a person has swallowing difficulties, food which moves rapidly or is very thin may be uncontrollable and life threatening when the tongue is more forward. In such cases, the tongue retracts, resulting in reduction of the size of the pharyngeal opening. This pattern is associated with abnormal increased muscle tone. Asymmetrical tongue placement or movement - The tongue deviates to one side or the other and may show atrophy on the affected side. It may be accomplished by or associated with abnormal tone in the facial musculature. All movements of the tongue are affected. The tongue deviates, or is pushed toward the weak side. If lateral tongue movement is consistently observed only to one side, it may not be active lateral movement, but rather may be asymmetrical movement toward the weak side. A Hypotonic tongue - The tongue may appear thickened and shows little or no active movement. Fasciculations, small, uncoordinated movements over the body of the tongue, may be observed when the tongue is at rest. These movements may increase during eating, drinking, swallowing and vocalizations. Dystonic tongue movement - The tongue rhythmical, nonfunctional movement of the tongue associated with Parkinson's or Parkinson's like symptoms. The ability to interrupt the movement is related to the severity of the disease. With less severe involvement, the pattern can be interrupted during functional activities such as eating or speech, and will not be observed during sleep. Tongue fasciculations - An abnormal pattern of nonrhythmical, unorganized contraction of individual muscle fibers across the surface of the tongue. May be observed when the tongue is at rest, or following direct stimulation to




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the tongue. May also be observed during generalized hypertonicity or hypotonicity affecting the whole body. Ankyloglossia - A structural impairment consisting of a shortened lingual frenulum. Body of the tongue is thinned, with the lateral borders elevated. A heart shaped indention may be noted at the front edge of the tongue. Function is limited if the tongue tip can lift less than 1/4" above the lower incisors. Pseudo Ankyloglossia - A functional impairment in which the body of the tongue is thickened and retracted. The lingual frenulum appears as a prominent white fiber at the center of the tongue tip. The end of the tongue is blunt and thick. Normal Cheek Patterns Normal cheek patterns include protrusion, retraction, and compression. The cheeks form the walls of the face. The cheek is composed of many layers of muscle tissue, inserting at many different angles. The cheeks assist in repositioning food in the sides of the mouth, in placing food between the teeth for chewing and in moving the food, fluid or saliva to the posterior of the oral cavity for swallowing. The muscles of the cheek assist with lip, jaw, and tongue movement. The receptors for swallowing are located in the posterior area of the cheeks, as well as on the gums, tongue and soft palate. Some of the salivary glands are located in the cheeks. Abnormal cheek patterns include hypotonicity (decreased muscle tone in the cheeks), hypertonicity (increased muscle tone in the cheeks), fluctuating tone, and atrophy due to disuse. These are often seen in combination with abnormal jaw, tongue and lip patterns. Each of these impacts on oral function. If the above patterns exist, there may be decreased awareness of what is happening in the oral area. Control of substances in the mouth will be adversely affected. The level of oral-motor response may change, based on the texture of food presented, or on the type of handling or feeding equipment the caregiver uses.




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Dysphagia - defined as difficulty in swallowing or the inability to swallow. This may be due to pressure imbalances, structural changes or abnormality in innervation of the pharyngeal or esophageal muscles. The ability to swallow may also be affected by more readily remediated oral mechanical problems. Dysphagia due to innervation problems or structural deviations at the second and third stages of swallowing should be differentiated from difficulty in the first stage (oral), which may be favorable improved through positioning, handling techniques, and techniques to control the flow and placement of food and fluids. Swallowing difficulties may lead to short-term problems, such as coughing, and long-term problems, such as aspiration, pneumonia and scarring of the lungs. Knowledge of a child's swallowing abilities will assist in determining strategies for controlling positioning and the flow and placement of food and fluids to encourage more efficient swallowing. Drooling: Loss of saliva from the mouth may occur for a variety of reasons. Gum or tooth disease, reflux, upper respiratory infections, allergies, mouth breathing, body position, level of activity or alertness, intensity of concentration, and impaired patterns of movement for the lips, cheeks, tongue and jaw may also result in drooling. Programs emphasizing conscious control of saliva are not effective. Evaluation of all factors affecting saliva control is essential for planning effective interventions to reduce drooling. Gagging is a protective reflex. It may be elicited by a number of different stimuli including: olfactory (smell); visual; touch to the posterior third of the palate, inner gums or tongue; touch to the pharynx; stimulation of the vagal nerve in the intestinal track; and stimulation of the semicircular canals in the inner ear following rapid movement of the head or body. Gagging may also occur if a more functional oral response, such as muscle contraction, chewing or swallowing, is not present due to oral motor impairment. By providing controlled pressure and movement on the face and within the mouth, an individual with oral motor impairment can develop those more functional responses, so that gagging is normalized. The goal is to normalize the gag, not to extinguish it. The gag is necessary for protection of the body from unfamiliar or harmful stimuli.

AN ORAL MOTOR PERSPECTIVE ON DROOLING Drooling, or loss of saliva from the mouth, may occur for a variety of reasons. Gum or tooth disease, upper respiratory infections, sinus infections, allergies, middle ear infections, gastroesophageal reflux, medications, mouth breathing, body position, level of activity, intensity of concentration, and level of alertness may affect control of secretions and may result in drooling. Abnormal patterns of movement or muscle weakness for the lips, cheeks, jaw and tongue may also result in drooling. The focus of this article is drooling due to abnormal patterns of movement or muscle weakness, both of which may occur in individuals with low muscle tone. To effectively and efficiently control oral secretions, the muscles and structures of the oral areas must constantly make subtle adjustments, twenty four hours a day. The sensory awareness at the lower cheeks, gums and lips must be present to detect the small changes in pressure on these tissues, which occur as saliva leaves the salivary ducts and enters the mouth. Range of cheek movement and lip movement for closure is necessary to maintain the negative intraoral seal during oral transit for swallowing. Lip power must be adequate to maintain the lips in a closed position during the swallow. The posterior cheek muscles must squeeze in toward the teeth and gums to shift the saliva to the center of the mouth for swallowing. The jaw must elevate to support the midblade of the tongue as it lifts up to contact the hard palate and propel the saliva into the pharynx. The soft palate must elevate during the swallow to close the nasal cavity and to maintain a negative pressure seal within the mouth. Humans secrete an average of .5 to 1 Liter of saliva a day and .5 ml per minute during sleep. Due to the quantity of secretions, and the many coordinated patterns of muscle movement needed to




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swallow the saliva consistently, conscious control of secretions is not possible for anyone during waking hours, and certainly is not possible during sleep. For this reason, interventions emphasizing conscious control of saliva usually show poor results over time, and may result in undue frustration for the individual. Medications or surgery which reduce the amount of saliva produced, without addressing any underlying oral motor issues, offer partial solutions, but are complicated with potentially serious side effects. Surgical interventions are considered permanent and irreversible. Before proceeding with either of these options, a six-month trial of oral motor therapy is recommended. To determine the muscle areas involved, a baseline of the components of muscle movement must be determined. These components include response to pressure and movement, range of movement, variety of movement, strength of movement, and control of movement. The areas assessed include the lips, cheeks, jaw, tongue and soft palate. Observation of the face at rest, and during activities such as eating, drinking, talking, and during change in facial expression are important. The structures of the face and mouth should be inspected visually for alignment and symmetry. In addition to observation, the lips, cheeks, jaw, tongue and soft palate can be manipulated manually, using the Beckman Oral Motor protocol, to add data regarding the components of movement listed above. This is especially important if the individual is nonverbal, on nonoral intake, or cannot follow commands. Findings from this baseline will yield data critical to the design of an effective intervention program. The focus of oral motor intervention will be determined by the baseline assessment. Some examples of interventions might include increasing sensory awareness at the gums and inner lower cheeks, increasing passive range of cheek and lip movement, increasing posterior cheek strength, increasing lip strength at the sides and center of the upper and lower lips, increasing internal jaw strength, increasing soft palate activation, and increasing the variety of intrinsic tongue muscle movements. Drooling may still occur intermittently, especially during the occurrence of teething, gum or tooth disease, upper respiratory infections, sinus infections, allergies, middle ear infections, gastroesophageal reflux, mouth breathing, increased level of activity, increased level of concentration, or decreased level of consciousness. The overall occurrence of drooling is reduced due to the increased internal oral motor control the individual has developed. Function is the focus of the treatment outcome.




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Sensory Motor Issues: ORAL HYPERSENSITIVITY OR DEFENSIVENESS, AN ORAL MOTOR PERSPECTIVE If parents report following comments about the child? "He gags all the time." "She fights me when I brush her teeth." "He hates it when I wash his face." "She won't let me wipe her nose." "He is a picky eater." "She overstuffs her mouth." "He grinds his teeth." "She chews on her fingers until there are calluses." "He drools all the time." "She won't chew her food." If so, child may be identified as having oral hypersensitivity or as being orally tactually defensive. Underlying the poor response to touch and movement on the face and inside of the mouth may be specific oral motor problems that occur if the muscles of the orofacial area lack adequate range of movement, strength of movement, and variety of movement. This affects control of movement and response to pressure and movement. By the third month of gestation, humans seek oral stimulation. The infant first finds this oral input from the amniotic fluid as the fetus sucks and swallows in the womb. The fetus also has been seen on ultrasound images placing the thumb into the mouth. The pressure and movement within the oral cavity tell the brain where the mouth begins and ends. Without such input, the location and boundaries of the mouth are uncertain to the infant. All that lip, cheek, jaw and tongue movement keep the eating machine in peak muscular condition. Movement against resistance is the best was to build strength. Repetition of movement is the best way to refine and develop muscle control. At birth, the infant frantically searches for something, preferably the breast, on which to suck. It is a reflexive pattern to insure nutritional intake. The mouth is equipped with lots of sensory receptors, ready for and craving stimulation. The mouth is the exploration cave of an infant. Since vision is not yet well developed, the mouth is the place for touch, taste, texture, with the added bonus of smell accompanying the oral experience. Early on, anything that can fit into the mouth is accepted for exploration. As the infant matures, discrimination of edible from non-edible items develops. Keep in mind that even as adults, we all continue to receive pleasure and comfort from a multitude of oral and facial stimuli. Baby ways to get stimulation are to suck or chew on things that are easy to reach, such as thumbs and toes. Pacifiers provide opportunities for non-nutritive sucking. Often pacifiers provide more comfort to the caregiver; since the baby's mouth is full, the crying is reduced. Body parts (thumbs and toes) are dynamic; moving and changing shape in the baby's mouth, providing a wide variety of pressure and movement. Pacifiers have a static shape. The stimulation from a pacifier is constantly at the center and front of the mouth. Because the movement of the lips and tongue stay the same while the pacifier is in the mouth, the baby can not practice the variety of movements so necessary for the continued development of internal jaw stability and muscle strength, which are needed to chew and later to speak. For an infant with normal muscle tone, development occurs without any major interventions by the caregivers. Skills which begin at the front and center of the mouth gradually change to include movement at the lateral and posterior areas of the mouth. For the infant with abnormal muscle tone, development of oral motor skills becomes more problematic, often with abnormal patterns of movement used to complete every day activities such as swallowing secretions, drinking, eating, vocalizing, chewing, and speaking in words or phrases. Because the muscles do not work together and do not give consistent pressures within the mouth, the individual may seek such input from external sources, such as clothing, toys, or other items. Many of these individuals have not progressed from pureed or soft foods, and so, are not receiving input on the jaw through chewing. The posterior area of the mouth may be receiving little or no input. Gagging (with or without vomiting) may result. The sensory input for the mouth is important, and the craving of such input does not decline for individuals on pureed diets or for those individuals with non-oral intake. It may be increased, resulting




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in pica - the eating of non-edible objects. Some individuals attempt to increase sensory input at the mouth by biting themselves, or others within their reach. Telling someone to stop putting everything into his or her mouth, or punishing him or her for doing so, does not address the underlying sensory motor needs. If the individual is hypersensitive, telling that person to stop gagging, or becoming angry when the individual refuses to do certain oral activities, does not address the underling sensory motor needs. By completing the Beckman Oral Motor protocol, the right kind of input can be provided in a safe way to enhance the muscle balance and internal muscle pressures the person should have, thereby reducing the constant craving for additional external input (mouthing of non edible items). Providing the right kind of input also normalizes oral sensitivity, so that the individual's response to pressure and movement is a functional movement, such as swallowing or moving the lips or tongue, instead of gagging, crying and screaming. Work with the therapist to develop the best intervention program to use at home for your loved one. By providing specific pressure and movement a little at a time (for three to five minutes) several times a day, significant changes can occur. This will make every day happier for you and your loved one.




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Risks of feeding or swallowing difficulties in children: • dehydration or poor nutrition • risk of aspiration (food or liquid entering the airway) • pneumonia or repeated upper respiratory infections that can lead to chronic lung disease • embarrassment or isolation in social situations involving eating Some causes of feeding and swallowing problems in children: • Nervous system disorders • Gastrointestinal conditions • Prematurity/low birth weight • Heart disease • Cleft lip or palate • Conditions affecting the airway

Sensory intetegration dysfunction Pervasive developmental disorder

Cerebral palsy




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Intervention for sensory issues:

- Intervention:

• Activities in between meals

- establish a relationship of trust with child

- playfully embed activities to desensitize into child's play activity

- gradually introduce sensory stimulating activities

• Desensitization

- encouraging exploration of mouth with his own hand

- rubber toys

- NUK brushes

- different degree of pressure

- Food of different textures

Activities to prepare for eating:

• Oral desensitization immediately before meal

• Deep pressure

• Firm rubbing

• Sustained firm pressure to upper palate

• Vibration

• Tactile stimulation

Meal time intervention:

• Modifying textures of food




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Modifying Postural alignment

good positioning

neutral alignment of trunk

Good head, neck & shoulder alignment

Chin tuck with back of neck slightly elongated

• Characteristics of feeding positions & positioning devices:

Infant held sideways in the caregivers arm

Infant held on caregivers thighs facing caregiver

Infant placed in infant seat




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Infant placed in cradle bouncer

Infant placed in a foam filled feeder seat

Infant placed in regular car seat

Child placed in s transport chair or wheel chair

Child placed in beanbag chair

Infant placed in high chair

• Improve oral transit

Head & jaw support

Thickened liquids

Positioning of head in flexion




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References:

1. Feeding and Swallowing Disorders, American Speech-Language-Hearing Association, www.asha.org

2.Morris, Suzanne Evans and Marsha Dunn Klein; Pre-Feeding Skills, Second Edition; Therapy Skill Builders; 2000.

3.Pre-Feeding Skills, Second Edition, by Suzanne Evans Morris and Marsha Dunn Klein, Therapy Skill Builders, 2000. 4. Feeding and Swallowing Disorders in Infancy: Assessment and Management, by Lynn S. Wolf and Robin P. Glass, Therapy Skill Builders, 1992. 5. Feeding and Nutrition for the Child with Special Needs, by Marsha Dunn Klein and Tracey A. Delaney, Therapy Skill Builders, 1994. 6. Beckman Oromotor Therapy


http://www.asha.org



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VIII. ADL’s of Children with Disability

Children with disability often need assistance in their ADL’s . The therapist should always consider putting his best efforts to train parents in the ADL’s. Most of the children with developmental difficulties have problem with feeding. There is a need for the PT, OT and SLT to work collectively towards ADL’s of the child or in other words we need to understand the work of other interdisciplinary areas. Finding out from the family about the resources that help in the children’s ADL’s. Often this resource is the mother, sibling or a caregiver. We should find out from the caregiver about the problem areas and provide information and hands on skill in the related areas. For children who have not achieved even sitting there is need for supporting/adaptive devices to facilitate there ADL’s.

Detailed information on ADL’s and kind of adaptive device is given in the pdf book by Indian Institute of Cerebral Palsy with a title-“ CP cleanliness”




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Bobath Concept- Techniques of Proprioceptive and Tactile Stimulation

By B.Bobath, F.C.S.P

The western Cerebral Palsy Centre,

London, England.

In ataxic children and in some children of the athetoid group in whom hypotonia and impaired reciprocal innervations make postural control and guidance of movement difficult, techniques to increase postural tone and to regulate the interplay of agonists, antagonists and synergists are used. They are also used in some spastic or athetoid children, in addition to techniques of inhibition and facilitation, if postural tone is too low and they seem to be weal in the absence of tonic reflex

activity.

The rationale of these techniques of Proprioceptive and tactile stimulation is probably similar to that underlying techniques of “maximal resistance” and “rhythmic stabilisation” as used by Kabat(1948, 1959) and Knott (1952), that is recruiting and summation by carefully applied and repetitive stimulation.

The techniques are used:

1. When there is apparent or real weaknees of muscles after hypertonus,i.e. spasticity or intermittent spasms, has been reduced or completely inhibited in treatment;

2. When there is sensory deficit with “weakness of muscles” due to lack of sensory input; 3. When there is no actual sensory deficit but the child does not know how to move because of

lack of previous sensori-motor experience or apraxia.

In applying these techniques it is necessary to avoid eliciting spasticity or intermittent spasms by stimulation of abnormal postural reflex activity. This can be avoided by:-

1. Combing techniques of stimulation always with reflex inhibiting patterns, in order to “shunt” nervous impulses into the desired channels and away from abnormal reflex patterns;

2. Stimulating carefully and only when postural tone is low, stopping the procedure immediately when tone becomes abnormally high. In fact techniques of stimulation are used in alternation with inhibitory techniques. It is desirable to anticipate abnormal reactions and to stop them before they gain momentum.

3. Aiming at localised responses, and avoiding wide-spread associated reactions. The main techniques are:-

1. Weightbearing, pressure ( compression), resistance; 2. Placing and holding (compression), resistance; 3. Tapping

These techniques can and should be used in combination or singly dependent upon the needs of the patient. They can be used alternatively or simultaneously.




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1. Weight bearing with or without pressure and resistance

Static postures should not be used, especially in the spastic child. Here intrinsic automatic movements of adjustments or trunk and limbs should be obtained by consistent weight transfer of fairly large ranges, sideways, forwards and backwards, and diagonally, while giving pressure and resistance. This can be done in various positions and activities, in supine, prone, sitting, standing and walking. In the athetoid and ataxic child the same techniques should be done slowly and be small in range. A combination of weightbearing, pressure and resistance can be used in all cases to obtain sustained postural tone for the maintenance of posture against gravity and for the control of involuntary movements.

2. Placing and holding

“Placing is a term used to describe the child’s ability to arrest a movement at any stage, automatically or voluntarily. In a normal person this can be demonstrated by moving his limb, for instance one arm, passively and with minimal support of its weight(lightly held and not supported by the therapist hand) and leaving it,i.e. letting it go, at various stages of a movement. The limb will then stay automatically for a moment where it has been released. The limb feels light when being moved as the normal person controls it actively and automatically throughout the whole range. “Placing may, therefore, be defined as the automatic adaptation of muscles to changes of posture and this is part and parcel of the normal postural reflex mechanism. This normal reaction to being “placed” is the prerequisite for the smooth stage of a voluntary movement.

In treatment the patient’s body and limbs are placed in various positions and he is made to hold and control them unaided in a great variety of functional patterns and at various stages and in various

ranges of movement.

3. Tapping

Tapping is frequently used in combination with placing; in fact it is a means of making “placing” possible.

Tapping is a means of increasing postural tone of the trunk or limbs by Proprioceptive and tactile stimulation. It is also used to increase activity of specific muscle groups.

The tapping is applied to a trunk, to a limb, or to part of a limb, at first at regular intervals in quick

succession, and gradually-when active responses occur- at irregular intervals and more slowly.

Tapping is only used when there is apparent or real weakness of specific muscle groups or general hypotonia,i.e. lack of sustained postural control against gravity. It must not be used in the presence of spasticity or spasm or when in the process of tapping such signs of hypertonous appear. The later may happen even if at the beginning of tapping was too slow. Tappping has then to be discontinued immediately and tonic reflex activity inhibited until there are no signs of hypertonous. Tapping can then be started again.




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All techniques of stimulation, but especially tapping, may elicit abnormal motor responses in children with cerebral palsy. It is advisable, therefore, to use tapping together with reflex inhibition posture.

The effect of tapping in producing increase of tone and contractibility of muscle is due to spatial and temporal summation and recruiting of nervous impulses of muscles. The first “taps” are sub-threshold and do not result in a response. In children with very low tone it may take a long time and a series of taps before a response can be noticed. Each tap must be followed by the next before the effect of the previous one has subsided. For this the taps should follow each other quickly at the begning. If the child is allowed to relax in between taps the effect is lost. On the other hand, if the taps follow each other too quickly, the child has no time to react to the therapist and the therapist ahs no means of judging the effect. Roughly speaking , tapping is started rather quickly and when the first response, i.e. the first muscular contractions are felt and the child begins to hold a limb or the

trunk actively, tapping is slowed down and the intervals between each tap are prolonged so that the therapist can judge how long the effect of previous tapping lasts. At the first signs of child relaxation tapping is restarted. Often it is necessary to give one or two taps to restore activity again. The rhythm of tapping should be changed frequently once the response has been elicited because, if the child gets used to certain rhythm, he becomes inactive and relies on the therapist’s support. But when the rhythm of tapping is frequently changed the child begins to control his trunk and limbs automatically as a protection against falling. The taps have to be given sharply and the part of the body touched only for a split second and left unsupported in between taps, so that the child can take over actively when unsupported. If the therapist’s hand becomes too long, the child’s reactions following a series of “taps” have to be carefully observed and the rhythm and direction of the tapping changed according to his reactions.

Tapping is used more in athetoid and ataxic children than in spastics, whose muscle tone is usually sufficient for the maintenance of posture against gravity when the interference of tonic reflex activity has been eliminated by reflex inhibition. However, tapping to improve balance reaction i.e, the activation of movements of adjustment to changes of posture, is much more in spastic children.

There are four types of tapping:-

1. Inhibitory tapping

2. Pressure tapping

3. Alternate tapping

4. Sweep-tapping

Tapping serves

a) To activate “weak” muscle groups, which cannot contract as a result of reciprocal inhibition by spastic antagonists (inhibitory tapping);

b) To increase postural tone for the maintenance of posture against gravity (pressure tapping);




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c) To obtain proper grading of reciprocal innervations, and to stimulate balance reactions (alternate tapping);

d) To activate synergistic patterns of muscle function by stimulating the specific group of muscles responsible for that action with a sweeping stroke in the direction of the desired movement (sweep – tapping).

1. Inhibitory tapping

This is designed to increase the function of muscles which cannot contract because fo the excessive activity of their hypertonic antagonists. Therefore hypertonous has first to be reduced in reflex- inhibiting patterns with elongation of the hypertonic muscles groups and shortening of the “weak” inactive ones. When there is no hypertonous but also no ability of the child to hold the desired position, tapping is done by momentarily releasing the part of the body to be held by the child, but by catching it immediately before it drops more than a fraction. This produces each time a small stretch of the shortened inactive muscle groups in their inner range. By repetition it builds up tone in these muscle groups and enables the patient to hold the position. (Isometric contraction.)

The muscles themselves are not touched. The tapping is due towards the direction of the functional pattern.

It is called “inhibitory tapping” because the main purpose is that of obtaining function through inhibition, but while inhibiting hypertonous it facilitates activity in opposite muscle groups.

2. Pressure Tapping.

It is designed to obtain co-contraction for sustained postural fixation. Pressure tapping stimulates simultaneous contraction of agonist and antagonists. This type of tapping is started from a “mid position” at which both agonists and antagonists have approximately the same length, and not in the inner or outer range of any muscle group. It is used mainly in athetoid and ataxias that show excessively mobility, lack of fixation and sustained postural tone. It is a very strong form of stimulation of joints and muscle receptors, and, if done with spastic children who are floppy when spasticity is under control, should be used with great care and discreation so that spasticity will not be produced or increased.

3. Alternate Tapping

This type of tapping is usually done as a follow-up of pressure taping, ie.e when a child is able to hold amid position steadily. It is most useful in athetoid and ataxias and in all children where there is imbalance of function of antagonists. It improves the grading of contraction and decontraction of agonists and antagonists. It is also useful in spastic children to stimulate and regulate balance reactions, and if used for this purpose of the technique of facilitation of automatic movements.

It is done by lightly tapping with the therepaist’s extended fingers as in inhibitory tapping.

4. Sweep-Tapping




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This type of tapping si difficult to describe because, though it is the only type of tapping applied to a specific muscle, it is done over the muscle with a sweeping stroke which activates, not only the muscle itself, but a whole pattern of muscle action.

It is in fact the stimulation of a pattern of function through the activation of the prime movers of that pattern.

The tapping is done with a sharp sweeping stroke of the therapist’s extended fingers along the length of the muscle or that of a number of muscles working in the same direction, and having a synergistic function.

Generally speaking, the positions which the child is made to hold, i.e. those in which he should be “placed” by tapping are:

1. Position which are essential for stability and fixation of the trunk, shoulder girdle and hips, in sitting, kneeling, and standing, so that free and independent movements of his head, arms and legs become possible.

2. Intermediate stages of those movements which the child cannot assume, or which, due to his lack of muscle tone or to imbalance of antagonists, he performs in a jerky uncontrolled way.




Terminology of treatment techniques

1. Reflex Inhibition posture- Postures which change (break up) pathological postural pattern

due to released tonic reflex activity.

2. Key points of control- Parts of body, mostly which proximal, from which pathological reflex

activity and strength and distribution of muscle tone in the rest of the body can be

influenced.

3. Inhibitory control- The ability to refrain from one action in favour of another. This includes

normal reactions to stimulation, i,e, responses which are in proper relation (adequate) to

the strength and type of the stimulus, choice of type of reactions and localisation of

response.

4. Facilitation of spontaneous movement- The stimulation of spontaneous movement

reactions, including righting and equilibrium reactions, in response to special techniques of

handling the child.

5. Facilitation of voluntary movement- By positioning of the child for specific voluntary

movements. Certain movements are easier to perform from certain postural sets.




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IX. Neurodevelopmental Therapy (NDT)

NDT is a problem- solving approach to the examination and treatment of the impairments and functional limitations of individuals with neuropathology, primary children with CP and adults with stroke and traumatic brain injury (TBI).

NDT is:-

• Holistic Approach

• Quality and coordination of movement patterns patterns

• Not simply individual muscle function and impairments Main components:

Main components:

- Normal movement patterns cannot be imposed upon abnormal ones

- Sensory motor experiences

History of NDT

Physiotherapist

Gymnast

Assisted by her husband,

Karel Karel, neurologist

Current Approach

Potential for recovery versus compensation

- Compensation is the natural response of injury

- Neuroplasticity- The brains ability to change and reorganize based on experiences.

- Recovery of function of involved side is possibly Neuroplasticity




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Person with a Health Condition

Body SystemsIntegrity/impairments

Motor FunctionsEffective/ineffective

Individual Activities limitation

SocialParticipation/Restrictions

Environment Facilitation/ Barriers

Health Condition/Disability

Environmental context and the health and condition or neuropathology

Objectives of NDT

• NDT focuses on analysis and treatment of sensorimotor impairments and functional limitations.

• NDT examination begins with identification of individual’s abilities and limitations.

NDT focuses on whole- Psychological, emotional, cognitive, perceptual and physical

• Therapeutic handling is an integral component of NDT

Neuro-developmental Functions Eight Constructs Functions-

1. Attention

2. Language

3. Memory

4. Spatial Ordering

5. Temporal Sequential Ordering Temporal

6. Neuro-motor Function




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7. Social Cognition

8. Higher Order Cognition

General Principles to be kept in mind:-

a) Speed of handling is very important.

b) Do not get the spastic and athetoid child to exert too much of effort as this will increase spasticity and produce associated reactions.

c) Be aware of the child’s tone.

d) Always start treatment proximally.

(e) Do not stick to the developmental sequence.e.g crawling not appropriate for spastic child with strong flexor pattern.

(f) Do not focus on one skill at a time.

(g) Start the treatment as early as possible

- Huge amount of development takes place.

- Child doesn’t learn negative movement patterns

- Carerer doesn't learn bad habits, less desirable handling techniques.

(h) No amount of treatment can be effective unless carried over in the home situation.

(i) Must have clear aims of each treatment session.

(j) Some children may well resist and fuss when handled, especially when they are placed in postures not familiar to them. Often fear being handled.

k) As the child gains control, PT must respond by moving key points of control from proximal to distal points.

(l) There is no gurantee that what works for one child will work for similar child.

(m) One needs to be a good role model and demonstrate to the caregiver how to integrate the technique into the daily routine.




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Key elements of NDT

1) Alignment- Cannot impose normal movement on mal-aligned joints

2) Handling- Inhibition, facilitation, key points

3) Placing- Assisting patients in achieving the appropriate position through alignment and handling.

4) Practice- team approach; functional; sensory-motor experience

Principles of NDT

Individualized Functional Outcome

Know the patient

- Life roles

- Support system

- Home environment

- Patient’s goal for therapy

Know the patient’s impairment

- Resulting from CVA

- Co-morbidities

- Functional activity Abilities and Limitation(FAA and FAL)

Treat the whole person

Individualized Functional Outcomes

Motor Control

- Systems approach

- Take advantage of synergies

Principles of NDT

4 Core elements




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-BOS

-Body support alignment

-Muscle activity

-Weight shift

10 Essential Factors

-4 Core elements

-Gravity

-Levers

-Time

- Distance

- Speed

- Environment

Main aspects of NDT treatment:-

- Starting posture

- Missing components of movement

- Manual cues

+Facilitation

+Inhibition

+Stretch

Starting posture

-most efficient position to move

-Improve muscle balance and alignment to achieve optimum length tension relationship

-Re-orient to midline

- “Neutral-alignment” to body segment




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- Sitting or standing

- Posture from which to compare normal and abnormal alignment and movement

- Missing components of movement

- -Assessment of alignment and movements in comparison to “normal”

- -Determine systematic reason for MCM (ROM, Neuromuscular, etc)

- - Drive the treatment session to obtain more “normal” alignment or movement.

The Assessment Process

NDT focus: to identify the client’s abilities and limitations in order to tailor an individualized treatment plan and provide a basis for comparing the client’s abilities at a later point in time.

Assessment consists of data collection, examination and evaluation.

The examination and evaluation is done at the beginning of treatment, before and after each session, at the end of each block of intervention, and at the end of the entire treatment.

Examination

NDT Focus: to identify constrains that limit the client’s ability to perform functional activities.

Components:

• Present and anticipated functional skills or limitation of skills

Initial contact

Data

collection

Evaluation

Analysis

Plan of care

(goals, objectives)

Intervention

plan

Re-examination

and evaluation




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• Posture and movement components and compensatory strategies

• Anatomical and physiological status of those systems that contribute to functional limitations

Functional Skills

Gross and fine motor control, communication, and control of behavior and emotions

• Functional abilities and limitations

• Potential to change function

• Clusters of function and activity limitations

• Relationship between participation and activity level

• Assistive devices, splinting and orthothics

Observation of posture, movement and compensatory strategies

• Spontaneous posture and movement

• Typical and atypical posture and movement

• Compensatory movement strategies

• Alignment, weight bearing, balance, coordination, muscle and postural tone, and movement components

Individual systems related to function

• Neuromuscular system

• Musculoskeletal system

• Sensory, perceptual, cognitive systems

• Regulatory system (arousal, attention, emotional and behavioral responses)

• Limbic system (emotions, fear, pain)

• Respiratory, cardiovascular system

- Integumentary system (skin)

Measurement Tools




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• Norm-referenced tests (WeeFIM, AIMS, The School Functional Assessment)

• Criterion-referenced tests (COPM)

• Non-standardized tests (compare the performance at the beginning and at the end of the session)

Evaluation

The therapist observes, describes and formulates hypothesis, linking treatment planning with outcomes.

• Client’s internal and external resources

• Functional limitations and participation restrictions

• The relationship between posture and movement components

• Hypotheses regarding impact of impairments on daily life function

• Potential to change

• Intervention plan developed

Principles of NDT

Manual Cues

- “Key points” of control

- Facilitate active alignment/movement

- Inhibit ineffective alignment/movement

- Stretching to tight muscles

- 4 primary cases:

+Establish the BOS

Align body segments

Activate the muscle activity

Assist the weight shift

Facilitation




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Using manual cues to assess muscle activity

-determine clients activity to initiate and sustain muscle activity for function

-Assist the muscle activity to control a posture or for transition

- Neuromuscular impairments

Inhibition

-Inhibit ineffective movement strategies

-Maintain or control a posture which the client is unable to do their own

Stretch

- Assess ROM

- Techniques to increase available ROM

- Musculoskeletal impairment

- Integrating NDT techniques

- -Bed Mobility

- -Transfers

- -Gait

- -ADLs

- -IADLs

Normalization of muscle tone

• Weight bearing over affected side

• Trunk rotation

• Scapular rotation

• Ant. Pelvic tilt

• Facilitation of slow controlled movements

• Proper positioning




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Key Points of Control

These are body parts from where the most effective control and change in pattern of posture and movements in other body parts can be achieved. These can be used for inhibition, facilitation of a movement for stimulation.

Proximal Key points Distal Key points Head Elbow Neck Wrist Shoulder Knee Trunk Ankle Pelvis Big toe Hip Thumb

1. Extension of head with extension of the shoulder- a) Raising the head in prone-lying, in sitting and standing will facilitate extension of the rest of the body. If raising the head produces total extension pattern it is useful in prone lying and standing, but will interfere with hip flexion in sitting.

2.a) Arm and Shoulder girdle- All inward rotation with pronation of the elbows inhibits extensor spasms and is useful in athetoids, but in spastics it will increase flexor spasticity of neck, trunk, and hips, as well as in the legs.

- All outward rotation with supination and extended elbows inhibits flexion and increases extension in the rest of the body.

b) Horizontal abduction of the arms in outward rotation with supination and extended elbows inhibits flexor spasticity especially of the pectorals and neck flexors, and facilitates the spontaneous opening of the hand and fingers. It also facilitates abduction of the legs with outward rotation and extension.

c) Elevation of the arms in outward rotation inhibits flexor spasticity and downward pressure of the arms and shoulder girdle and helps extension of spine, hips and legs in spastic quadriplegics and diplegics.

d) Extension of the arms diagonally backwards, inhibits flexor spasticity as in horizontal abduction and may be more effective in severe cases and better to start with more than the former.




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e) Abduction of the thumb with the arm in supination. Outward rotation and extension facilitates opening of all fingers. Wrist should be extended.

3. Legs and Pelvis

a) Flexion of legs favors (facilitates) abduction and outward rotation as well as dorsiflexion of ankles.

b) Outward rotation in extension facilitates abduction and dorsiflexion of ankle.

c) Dorsiflexion of toes, especially of the outer 3 or 4 toes, inhibits extensor spasticity through the leg and facilitates dorsiflexion of the ankle, as well as outward rotation and abduction of the leg.

4. Prone

a) Head raised, arms extended above head, spine extended, facilitates extension of hips and legs.

b) Same as above with horizontally abducted extended arms, facilitates extension of hips and legs.

c) Head to one side, while lifting it up, facilitates flexion abduction of the leg of that side and movement of arm upwards as in creeping.

5. Supine

In young children( not very spastic) but with neck and shoulder retraction, flexion of the legs in abduction against the abdomen, with some pressure downwards, facilitates the child’s arms moving forwards and hands engaging in midline.

6. Sitting

a) Flexion of hips, trunk forwards, legs abducted, facilitates extension of spine and head raising, sitting makes this easier.

7.Kneelstanding, standing, walking

a) Flexion of arms with pronation and inward rotation and flexion of the dorsal spine inhibits extensor spasms and hyperextension of hips and knees in athetoids, but produces flexion at hips and knee in spastics.




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b)Extension of arms in outwards rotation, holding them slightly diagonally backwards, inhibits flexor spasticity of trunk, hips and legs in spastics, and facilitates extension of spine, hips and legs with outward rotation and abduction.

8) 4 point kneeling with weight bearing with extended arms and open palms.

It is facilitated by lifting the child’s shoulder-girdle up and pulling his shoulders backwards. This prevents excessive protraction of the shoulders. Inhibits flexor spasticity and adduction of the arms and facilitates extension, abduction and the opening of hands and fingers.

9) Half Kneeling

Child’s pelvis is rotated backwards on the side of the non-weight bearing leg ,i.e. of the one in front. This stabilizes the pelvis and prevents adduction and flexion of the leg in front, as well as flexion of weight bearing leg.




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Methods of assessing tone

Methods of assessing tone

1. Observation of Movement

a) Recognition of the abnormal synergies (patterns of movement) associated with spasticity.

b) Recognition of persistent or fluctuating abnormal movements and postures.

2. Handling

a) Feeling of the limb

b) Appearance of the limb

Assessment of movement and function

1) The components of a function which are missing or abnormal and the effect of this on performance.

2) The effectiveness of the postural background to function, that is, the body’s reaction to gravity.

3) The effect upon function of abnormal tone, involuntary, athetoid or tremors movements, ataxic Inco-ordination of movement and sensory dysfunction.

Intervention

Sequence of Intervention

• Preparatory activities for passive movement or body alignment

• Selection of the key points for therapeutic handling according to the child’s postural tone

• Facilitation of active or automatic movement patterns by applying graded and varied therapeutic input




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XII. Conductive Education

• Andras Peto in Budapest, Hungary, originated conductive education. Since Professor Peto’s death, the work has been continued by Dr.M. Hari( Cotton 1965,1968,1974). The main feature is the integration of therapy and education by having:

• A conductor acting as a mother, nurse, teacher and therapist. She is especially trained in habilitation of motor disabled children in a four year course. She may have one or two assistants. The group of about 15-20 children, work together. Groups are fundamental in this training program.

• In all-day programme a fixed time-table is planned to include getting out of bed in the morning, dressing, feeding, toileting, movement training, speech, reading, writing and other school work.

• The movement’s sessions of movements take place mainly on and bedside slatted plinths (table beds) and with ladder-backed chairs. The movements are devised in such a way that they form the elements of a task or motor skill. The tasks are carefully analysed for each group of children. The tasks are activities of daily living, motor skills including hand function, balance and locomotion. The purpose of each movement is explained to the children. The movements are repeated, not only in the movement sessions of say,the hand class or plinth work, but also in various contexts throughout the day. The children are shown in practise how their “exercises” contribute to daily activities.

• Rhythmic intension. The technique used for training the elements or movements is rhythmic intension. The conductor and the children state the intended motion. ‘ I touch my mouth with my hands’. This motion is then attempted together with their slow, rhythmic counts of one to five. Motion is also carried out to an operative word, such as ‘up’,up, ‘up’ repeated in a rhythm slow enough for the children’s active movement ability, speech and active motion reinforce each other.

• Individual sessions may be used for some children to help them to participate more adequately in the work of the group.

• Learning principles are basic to the programme. Conditioning techniques and group dynamics are among the mechanisms of training discussed. Cortical or conscious participation is stressed, as opposed t involuntary and unconscious reflex therapy. They feel reactions to handling cannot create active learning by child.

Refrences:

http://www.peto.hu/en/


http://www.peto.hu/en/



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XIV. Play

Definition: To occupy oneself in amusement, sport, or other recreation.

If you play Peek-a-boo because you want the child to learn to reach out with his/her hands to take the cloth from his and/or from your face there should be interaction; very small children usually love this game. And by

the interaction the child learns to communicate, to take turns, to see that even if s/he cannot see the face of

mummy anymore she is still there behind the cloth

A child learns new things by a lot of repetition

A child stands up a thousand times before s/he will be able to walk. A child do that because there is a reward: either something s/he wants to play with, or something s/he wants to eat or drink, or his/her parents

praise for the efforts

Toys for early stimulation

0- 1YEAR

Hanging toys must be bright colourful and soft melodious sound making

Early stimulations is mostly indoor, so the environment should be attractive




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2-3 years

The developing child learns from play, now the toys should focus on mobility, learning

3-5yrs




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By 2 years the typical physical development is almost complete, now the toys should be provided keeping in mind their social, cognitive, Speech and language development

XV. Biological and physiological importance of various

postures

The importance of different postures:-

Supine

1. It facilitates bilateral hand movements. 2. Provides opportunities for the child for visual learning from the environment. 3. A posture in which young children’s are feed

Prone

1. Facilitates prone on hands 2. Neck control 3. Weight bearing on shoulders and hands and in this way helps to strengthen scapula-

humeral and hand muscles

Side lying and rolling

1. Helps in the reflex inhibition (ATNR) 2. Bilateral hand movements 3. Transition to higher posture

Sitting

1. Facilitates control of pelvis and trunk muscles. 2. An important posture for more exploration of environment. 3. An important posture for feeding and learning. 4. Facilitation of bilateral hand movements 5. Development of balance and stability 6. Important for toilet training

Standing

1. An important posture for Physiological functions like- digestion, biostasis, facilitates blood circulation

2. Important for mobility 3. Important for weight bearing and strengthening of bones and joints




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4. Prevents osteoporosis 5. Micturation/Urination 6. Bathing

XVI. Therapy Equipments/Wooden Furniture for special needs:-

There are various wooden furniture’s available, but while prescribing any kind of wooden furniture we need to focus on what is purpose for which we are providing the support with wooden furniture? How to take assessment of the furniture? When the furniture is made it we should recheck if it meets the requirement? Training of the parents on the use of furniture, we can use our local carpenter to make these furniture, we must always focus to prescribe cost effective/low cost tools as the child would be developing and would require more supports in the future.

Some common wooden furniture’s pictures are mentioned below:-

Corner Chair

Customised chair for specific need




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It is often helpful if the seating is adjustable, allowing the child to sit in positions for stimulation as well as for relaxation.

Design a seat that helps a child to lift his head and use his hands.




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Some children may require in ADL’s

Paediatric Therapy Equipments

Wedges Bolsters/Wedges Peg board




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Activity training board Modified utensils Swings/Therapy mat

Equipments used in Conductive education

Supported standing with petto chair




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XVI. Do’s and Don’ts in CP

1. All pre-term neonates need to be given early intervention. 2. Maintain the child in correct posture so that it may inhibit the abnormal reflexes and

facilitate further development. 3. Start the oral feed as soon as possible. With the help of techniques to facilitate oral

musculature function.

4. The neurorehabilitation program for cerebral palsy changes over time. During the first 2 years of life, an infant stimulation program with an emphasis on more than just improving motor deficits is emphasized. The importance of involvement of a knowledgeable therapist cannot be overemphasized. Realistic expectations must be articulated firmly. Rather then cautiously attempting to correct a dysfunction that cannot be corrected, the therapist should help the patient develop compensation techniques; the severity of the disability frequently militates against the development of “normal” motor control. Educating the parents about cerebral palsy, showing how positioning can be an effective way of helping the child be mobile, and encouraging parent-child interaction are aspects of an infant stimulation program. The therapist should serve as a coach to the parents, who implement

much of the actual treatment on a daily basis at home. 5. From 2 to 5 years of age, rapid growth occurs, and muscle tone will either develop or

worsen—the latter leading not only to the development of contracture but also to a decrease in mobility. In developing a program to control this muscle tone, the most important question to be answered is, Can I improve the patient’s function and decrease the patient’s disability by altering muscle tone? It is not uncommon for the real problem preventing the patient from performing certain functions to be lack of motor control or lack of sensation and not the abnormal muscle tone.

6. Between 5 and 10 years of age, the child begins to approach adult height. At this time,

definitive orthopedic intervention can be considered; as already noted, contracture development occurs as a result of abnormal muscle tone in combination with growth

7. As the child approaches the ten years, issues of sitting and hygiene are important considerations, especially in the nonambulatory patient. The problem of pain secondary to spasticity or dystonia must be addressed.

8. Keep a mobile stand above the head so that the visual fixation, and hand uses develop in the child.

9. Look for the sequence of development-is is not always that the child always follows the sequence; if the child is not going to the next stage you may also look back to the sequence of development.

THE SEQUENCE REMAINS MORE OR LESS THE SAME IN

ALL THE POSTURES. HOWEVER




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a) It is not a rule that the child cannot move on to next higher posture without completing the

sequence of development in one posture. b) The child who is at a higher sequence level in one posture may be at a lower sequence level

in another posture. This concept is called ADVANCEMENT & REGRESSION. c) The child cannot do higher-level activities in one posture before being comfortable in the

particular position.

Head free –> Weight shift –> Saving -> Hands free –> Tilt –> legs free –> Pivoting ->

Moving out of posture.

10. Always look at the braces and orthoses whether they are tight fitting or hurting the child’s skin.

11. Plan for the therapeutic programme in such a way so that the parents of the child don’t have any additional financial burden, which they may utilize further in his life.

12. As you perform the exercises ask the parents to perform the exercises and note in on a copy and keep it with them.

13. Start weight bearing of the child by a year, as this will prevent the Hip dislocation (a major concern for the quadriplegics), and will also prevent osteoporosis.

14. If the child is nonverbal, let the child look for the other modes of communication (AUGMENTATIVE AND ALTERNATE COMMUNICATION, AAC) e.g eye pointing, hands

pointing, picture book etc. 15. Look for all the ADL’s are performed in correct posture, so that the child and the parent have

fewer problems. See the abilities of the child always encourage him to participate more and more.

16. Encourage parents to add salad and fruits of the child, as the children with C.P commonly present with constipation.

17. By three years ask the parents to admit their child in a play school, as this will increase the Childs abilities and encourage his development with peer interaction.

18. A lot of children with C.P do present with multiple disabilities, so we may need BEHAVIOUR MODIFICATION TECHNIQUES.

19. Always document the child’s visit, as this will give you idea about the prognosis. 20. Look for the child as a child and not as a PERSON WITH DISABILTY.

DON’T

1. Do not massage the child, as this will increase the TONE. 2. Do not always keep the child on liquid diet. 3. Do not keep the child always in the same position. 4. Do not always help the child to do his ADL’S. Explain him the way to do, as and when he

needs assistance give him the assistance. 5. Don’t look for what he cannot perform look to his abilities and strength. 6. Do not keep the child in a wrong posture.




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7. Don’t look for the appliances and material that may not be easily available to the

parents.




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Karuna Vihar EIC

Standing frame cum sitting chair – Assessment Form

Date: _____/_____/ 20__ Name of Child- ............................................. ........ Age/Gender- ......................................................... Weight (Kgs) …………………………………………............... Height (inches) ………………………………………................. Contact Details ………………………………………................ Assessor ……………………………………………….......... ………………………………………………......... Brief description of Neurological Impairment and associated secondary issues: ………………………………………………………………………………………………………………………................................................................................................................................................... ……………………………………………………………………………………………………....... ……………………………………………………………………………………………………… ……………........…………………………………………………………………………………… ......................................................................................................................................................... .........................................................................................................................................................




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.........................................................................................................................................................

Measurement for Sitting Chair:

Note: Assessment for sitting is done with child sitting on the low level stool with back unsupported.

Measurement for Standing Frame:

TYPE OF STANDING FRAME

Prone stander/Supine stander

With inclination/w/o inclination

Measurements with standard inch tape In Inches

Heel to Occiput

Heel to Acromian Process

Heel to Inferior angle of scapula




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Heel to PSIS level

Heel to knee

Pelvic width

Standing Frame Measurement In Inches

1. Height of Standing Frame

2. Width of Standing Frame

Table/Desk Measurement

Length and width -

Depth of the circumference –

C size (Right to left midaxillary line with centre at xiphisternum) -

Longitudinal depth (Perpendicular line intersecting between midaxillary line and xiphisternum)-

Table Height:

Sitting chair (From buttocks to Olecranon process of elbow, when child is in sitting on a stool and

elbow flexed to 90 degree)-

Standing frame (from bottom of heel to Olecranon process of elbow with elbow flexed to 90

degree)-

Additional supports:- In Inches

Belts=

At the level of T2-T8(Chest belt)

At the level of Pelvis

Chest Harness

Velcro=

At the level of 2 ‘’ above Knee

2 At the level of 2 ‘’ below Knee




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At the level of 2 ‘’ above medial malleolus

Mid foot level

AFO/Knee Gaiters/Arch Support/any other orthotic

Note: Assessment for standing frame has to be done in supine lying position.

Please describe any functional limitations not mentioned above, giving dimensions where

appropriate:-

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Signature and Name of Therapist




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Latika Roy Foundation-“Paediatric Rehabilitation Therapy Course” (16th-27th August 2010)

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Problems with communication

Problems with Movement

Problems using Hands

Cannot respond to parents voice

Cannot hold head up

Cannot play with own hands

Cannot copy sounds and actions

Cannot roll over

Cannot reach

Cannot ask for things

Cannot up on the floor

Cannot hold a toy

Cannot use words

Cannot crawl

Cannot use 2 hands together

Cannot sit alone

Cannot stand

Cannot walk





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In the pictures from “watch us grow” please mark the approximate developmental age of child with pencil.

Raises Chest, holds head up

Sits with help

Holds head up in sitting Rolls onto back

Crawls and sits with head up

Likes sitting and playing

Can look around while playing

Sits, plays with both hands

Walks and runs well

Climbs and sit

Likes active play

Sits and balances





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Takes weight on leg Runs and jumps

Stands with support Holds and looks at toy

Stands holding on Puts toys in and out

Stands and walks Uses spoon

Squats and plays Picks up things with thumb and fingers

Runs and jumps Dresses self





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Looks and reaches Listens and watches Cries

when startled

Turns to look

Turns to sound

Likes making sounds

Looks and points

Listens to sound Uses single words

Looks, searches and finds objects

Turns to follow sounds

Uses 2 to 3 words together

Looks and names

Follows instructions Has simple conversation

Identifies things at a distance Listens and asks questions

Speaks fluently





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Likes playing

Plays with both hands

Imitates actions Plays beside others

Uses imaginative play and likes group games

Likes Group games





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List of available resources on the Internet 1. http://apps.who.int/classifications/icfbowser/

2. www.cebp.nl

3. www.wcpt.org

4. www.apta.org

5. www.gfmer.ch

6. www.ncbi.nlm.nih.gov

7. www.cre.sagepub.com

8. www.neurologyindia.com

9. www.medworm.com

10. www.physiobase.com

11. www.physiotherapyjournal.com

12. www.cerebralpalsy.org

13. www.downs-syndrome.org.uk

14. www.childdevelopmentinfo.com

15. www.firstsigns.org

16. www.prisms.org

17. www.babycenter.com

18. www.ndta.org

19. www.brainandbehaviour.ie

20. www.bobath.org.uk

21. www.suittherapy.org

22. www.spdfoundation.net

23. www.birth23.org

24. www.wfot.org

25. www.asha.org

26. www.aifo.it

27. www.who.int/childgrowth/en/


http://apps.who.int/classifications/icfbowser/

http://www.cebp.nl

http://www.wcpt.org

http://www.apta.org

http://www.gfmer.ch

http://www.ncbi.nlm.nih.gov

http://www.cre.sagepub.com

http://www.neurologyindia.com

http://www.medworm.com

http://www.physiobase.com

http://www.physiotherapyjournal.com

http://www.cerebralpalsy.org

http://www.downs-syndrome.org.uk

http://www.childdevelopmentinfo.com

http://www.firstsigns.org

http://www.prisms.org

http://www.babycenter.com

http://www.ndta.org

http://www.brainandbehaviour.ie

http://www.bobath.org.uk

http://www.suittherapy.org

http://www.spdfoundation.net

http://www.birth23.org

http://www.wfot.org

http://www.asha.org

http://www.aifo.it

http://www.who.int/childgrowth/en/



Peadiatric Rehabilitation -course-book

Health & Medicine

Transcript of Peadiatric Rehabilitation -course-book