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  1. 1. PediatricsThe branch of Medicine thatdeals with any disturbancesof the health or the orderlygrowth and development ofthe child.A report by:Kenneth Pierre M. Lopez
  2. 2. Theories of Development,Motor Control and Learning
  3. 3. Development The sequence of events through which the individual grows, changes, evolves and matures Theories of Development  Maturationist Theory  Individual genetically and biologically determined  There are preformed innate aspects of human behavior  Empiricist Theory  Source of human behavior is the environment  Behavioral Theory  Environmental reinforcement is the motivator and shaper of cognitive and motor behavior  Used in behavior modification treatment where desired behaviors are positively reinforced and unwanted behaviors are ignored
  4. 4.  Interactionist Theory Child is an active social being who contributes to his development Piagetian Theory Interaction of environment and neural maturation results in spiraling of development with equilibrium and disequilibrium resulting.
  5. 5. Motor Control The study of postures and movements and parts of mind and body which control posture and movement. Theories of motor control  Neuromaturationist theory  Cortex is command center with descending control and inhibition of lower centers by higher ones in central nervous system  Systems theory  Command center changes from cortex to other levels depending on task  Stresses interaction between brain, body and environment including biomechanics and body geometry
  6. 6.  Sensory systems mature, become integrated and connected to muscle coordination patterns starting with visual system  Immature postures involve cocontraction of agonists and antagonists, cocontraction decreases with maturation Neuronal group selection theory  Genetic code of species outlines limits of neural network formation  Actual network formation results from individual experience  Cell death of unexercised synaptic and strengthening of synaptic connections selectively activated
  7. 7. Principles of Motor Development1. Occurs in cephalocaudal direction2. Unrefined to refined movement3. Stability to controlled mobility4. Occurs in spiraling manner, with periods of equilibrium and disequilibrium5. Sensitive periods occur when infant/child is especially affected by environmental input
  8. 8. Infant reflexes and possible effects if reflex persists abnormally
  9. 9.  Asymmetrical Tonic Neck Reflex (ATNR)  Stimulus: Head position, turned to one side  Response: Arm and leg on face side are extended, are and leg on scalp side are flexed, spine curved with convexity toward face side  Normal age of response: Birth to 6 months  Interferes with:  Feeding  Visual tracking  Midline use of hands  Bilateral hand use  Rolling  Development of crawling  Can lead to skeletal deformities (scoliosis, hip subluxation/dislocation)
  10. 10.  Symmetrical Tonic Neck Reflex (STNR)  Stimulus: Head position, flexion or extension  Response: When head is in flexion, arms are flexed, legs extended. When head is in extension, arms extended, legs are flexed  Normal age of response: 6 to 8 months  Interferes with:  Ability to prop on arms in prone positions  Attaining and maintaining hands and knees position  Crawling reciprocally  Sitting balance when looking around  Use of hands when looking at object in hands in sitting position
  11. 11.  Tonic Labyrinthine Reflex (TLR)  Stimulus: Position of labyrinth in inner ear- reflected in head position  Response: In the supine position, body and extremities are held in extension; in the prone position, body and extremities are held in flexion  Normal age of response: Birth to 6 months  Interferes with:  Ability to initiate rolling  Ability to prop on elbows with extended hips when prone  Ability to flex trunk and hips to come to sitting position from supine position  Often causes full body extension, which interferes with balance in sitting or standing
  12. 12.  Galant Reflex  Stimulus: Touch skin along spine from shoulder to hip  Response: lateral flexion of trunk to side of stimulus  Normal age of response: 30 weeks of gestation to 2 months  Interferes with: Development of sitting balance Can lead to scoliosis
  13. 13.  Palmar Grasp Reflex  Stimulus: Pressure in palm on ulnar side of hand  Response: Flexion of fingers causing strong grip  Normal age of response: Birth to 4 months  Interferes with:  Ability to grasp and release objects voluntarily  Weight bearing on open hand for propping, crawling, protective response
  14. 14. Plantar Grasp Reflex  Stimulus: Pressure to base of toes  Response: Toe flexion  Normal age of response: 28 weeks of gestation to 9 months  Interferes with: Ability to stand with feet flat on surface Balance reactions and weight shifting in standing
  15. 15. Rooting Reflex  Stimulus: touch on cheek  Response: Turning head to same side with mouth open  Normal age of response: 28 weeks of gestation to 3 months  Interferes with: Oral-motor development Development of midline control of head Optical righting, visual tracking, and social interaction
  16. 16. Moro Reflex Stimulus: Head dropping into extension suddenly for a few inches Response: arms abduct with fingers open, then cross trunk into adduction; cry Normal age of response: 28 weeks of gestation to 5 months Interferes with:  Balance reactions in sitting  Protective responses in sitting  Eye-hand coordination, visual tracking
  17. 17. Startle Reflex  Stimulus: Loud, sudden noise  Response: Similar to Moro response but elbows remain flexed and hands closed  Normal age of response: 28 weeks of gestation to 5 months  Interferes with: Sitting balance Protective responses in sitting Eye-hand coordination, visual tracking Social interaction, attention
  18. 18.  Positive Support Reflex  Stimulus: weight placed on balls of feet when upright  Response: stiffening of legs and trunk into extension  Normal age of response: 35 weeks of gestation to 2 months  Interferes with: Standing and walking Balance reactions and weight shift in standing Can lead to contractures of ankles into plantar flexion
  19. 19. Walking (Stepping) Reflex  Stimulus: Supported upright position with soles of feet on firm surface  Response: Reciprocal flexion/extension of legs  Normal age of response: 38 weeks of gestation to 2 months  Interferes with: Standing and walking Balance reactions and weight shifting in standing Development of smooth, coordinated reciprocal movements of lower extremities
  20. 20. Developmental Gross and Fine Motor Skills
  21. 21. Newborn to 1 Month Gross Motor Skills Fine Motor Skills Prone  Regards objects in Physiological flexion  direct line of sight  Lifts head briefly  Head to side  Follows moving object Supine to midline  Physiological flexion  Hands fisted  Rolls partly to side  Arm movements jerky Sitting  Movements may be Head lag in pull to sit  purposeful or random Standing  Reflex standing and walking
  22. 22. 2 to 3 monthsGross Motor Skills Fine Motor Skills Prone  Can see further  Lifts head 90degrees briefly  Chest up in prone position distances with some weight through forearms  Hands open more Rolls prone to supine  Visually follows through  Supine  ATNR influence strong 180 degrees Legs kick reciprocally  Grasp is reflexive   Prefers head to side Sitting  Uses palmar grasp  Head upright but bobbing  Variable head lag in pull to sit  Needs full support to sit Standing  Poor weight bearing  Hips in flexion, behind shoulders
  23. 23. 4 to 5 monthsGross Motor Skills Fine Motor Skills Prone  Grasps and releases Bears weight on extended toys  arms  Pivots in prone to reach toys  Uses ulnar-palmar Supine grasp  Rolls from supine to side position  Plays with feet to mouth Sitting  Head steady in supported sitting position  Turns head in sitting position  Sits alone for brief periods Standing  Bears all weight through legs in supported stand
  24. 24. 6 to 7 monthsGross Motor Skills Fine Motor Skills Prone  Approaches objects  Rolls from supine to prone with one hand position  Holds weight on one hand  Arm in neutral when to reach for toy approaching toy Supine  Radial-palmar grasp  Lifts head Sitting  “rakes” with fingers to  Lifts head and helps when pick up small objects pulled to sitting position  Voluntary release to  Gets to sitting position without assistance transfer objects  Sits independently between hands Mobility  May crawl backward
  25. 25. 8 to 9 monthsGross Motor Skills Fine Motor Skills Prone  Develops active Gets into hands-knees position  supination Supine  Does not tolerate supine  Radial-digital grasp position develops Sitting  Moves from sitting to prone  Uses inferior pincer position grasp  Sits without hand support for longer periods  Extends wrist actively Pivots in sitting position  Points with index finger  Standing  Stands at furniture  Pokes with index finger Pulls to stand at furniture  Release of objects is   Lowers to sitting position from supported stand more refined Mobility  Takes objects out of Crawls forward   Walks along furniture (cruising) container
  26. 26. 10 to 11 monthsGross Motor Skills Fine Motor Skills Standing  Fine pincer grasp  Stands without support development briefly  Pulls to stand using half-  Puts objects into kneel intermediate container position  Grasps crayon  Picks up object from floor from standing with adaptively support Mobility  Walks with both hands held  Walks with one hand held  Creeps on hands and feet (bear walk)
  27. 27. 12 to 15 monthsGross Motor Skills Fine Motor Skills Mobility Marks paper with  Walks without crayon support Builds tower using  Fast walking two cubes  Walkst backward  Walks sideways Turns over small  Bends over to look container to between legs obtain contents  Creeps or hitches upstairs  Throws ball in sitting
  28. 28. 16 to 24 monthsGross Motor Skills Fine Motor Skills Squats in play  Folds paper Walks upstairs and  Strings beads downstairs with one  Stacks six cubes hand held-both feet on step  Imitates vertical and Propels ride-on toys horizontal strokes Kicks ball with crayon on Throws ball paper Throws ball forward  Holds crayon with Picks up toy from thumb and fingers floor without falling
  29. 29. 2 YearsGross Motor Skills Fine Motor Skills Rides tricycle  Turns knob Walks backward  Opens and closes jar Walks on tiptoe  Able to button large Runes on toes buttons Walks downstairs  Uses childe-size alternating feet scissors with help Catches large ball  Does 12 to 15 piece Hops on one foot puzzles  Folds paper or clothes
  30. 30. 3 to 4 YearsGross Motor Skills Fine Motor Skills Throws ball 10 feet  Controls crayons Walks on a line 10 more effectively feet  Copies a circle or Hops 2-10 times on cross one foot  Matches colors Jumps distances of  Cuts with scissors up to two feet  Draws recognizable Jumps over obstacles human figure with up to 12 inches head and two Throws and catches extremities small ball  Draws squares Runs fast and avoids  May demonstrate obstacles hand preference
  31. 31. 5 to 8 YearsGross Motor Skills Fine Motor Skills Skips on alternate feet  Hand preference is Gallops evident Can play hopsotch, controlled hopping,  Prints well, starting and squatting on one leg to learn cursive Jumps with rhythm, writing control (jump rope)  Able to button small Bounces large ball Kicks ball with greater buttons control Limbs growing faster than trunk allowing greater speed, leverage
  32. 32. PediatricConditions
  33. 33. Cerebral Palsy An umbrella term used to describe movement disorders due to brain damage that are nonprogressive and are acquired in utero, during birth or infancy. The brain damage decreases the brain’s ability to monitor and control nerve and voluntary muscle activity.
  34. 34. Classifications of CP By area of body showing impairment  One limb – monoplegia  Two lower limbs – diplegia  Upper and lower limbs on one side of the body - hemiplegia  All four limbs – quadriplegia By most obvious impairment  Spastic – increased tone, lesion of motor cortex or projections from motor cortex  Athetosis – fluctuating muscle tone, lesion of basal ganglia  Ataxia – ionstability of movment, lesion of the cerebellum
  35. 35.  Gross Motor Classification of Cp  Level I  Walk without restrictions, limitations in more advanced gross motor skills  Level II  Walk without assistive devices; limitations walking outdoors and in the community  Level III  Walk with assistive mobility device; limitations walking outdoors and in the community  Level IV  Self-mobility with limitations; children are transported or use power mobility outdoors and in the community  Level V  Self-mobility is severely limited even with the use of assistive technology
  36. 36. Impairments for all classes of CP Insufficient force genration Tone abnormality Poor selective control of muscle activity Poor regulation of muscle activity in anticipation of postural changes Decreased ability to learn unique movements Abnormal patterns of movement in total flexion and extension Persistence of primitive reflexes  May interfere with normal posture and movement  May cause contractures and deformities
  37. 37.  Spastic CP  Increased muscle tone in antigravity muscles  Abnormal postures and movements with mass patterns of flexion/extension  Imbalance of tone across joints may cause contractures and deformities, especially of hip flexors, adductors, internal rotators and knee flexors, ankle plantar flexors of the LE, scapular retractors, glenohumeral extensors, and adductors, elbow flexors, forearm pronators  Visual, auditory, cognitive and oral motor deficits may be associated with spastic CP
  38. 38.  Athetoid CP  Generalized decreased muscle tone, floppy baby syndrome  Poor functional stability especially in proximal joints  Ataxia and incoordination when child assumes upright positions with decreased BOS and muscle tone fluctuations  Poor visual tracking, speech delay and oral motor problems  Tonic reflexes such as ATNR, STNR, TLR may be persistent, blocking functional posture and movement
  39. 39.  Ataxic CP  Low postureal tone with poor balance  Stance and gait are wide based  Intention tremor of hands  Uncoordinated movement  Ataxia follows initial hypotonia  Poor visual tracking, nystagmus  Speech articulation problems  May occur with spastic or athetoid CP
  40. 40. Interventions & Goals  Very individualized, depending on abilities, age, type of CP. Incorporate child and family in intervention planning, implementation and goal setting.  Focus on prevention of disability by minimizing effects of impairment, preventing or limiting secondary impairment such as contractures, scoliosis.  Utilize static (positioning) and dynamic patterns of movement opposite to habitual spastic patterns  Facilitate symmetry in postures  Elongate spastic hamstrings and heel cords  Serial casting may be used to increase length of muscle and decrease tone
  41. 41.  Emphasize maximizing gross motor functional level  Use principles of motor learning and motor control; facilitate the attainment of functional motor skills including voluntary movement, anticipatory and reactive postural adjustments. Use toys, fun activities, balls and bolsters to facilitate postural control and developmental activities  Use weight-bearing and postural challenge to increase muscle tone and strength  Incorporate orthoses and adaptive equipment as necessary
  42. 42. Down Syndrome (Trisomy 21)Chromosomal abnormality caused by breakageand translocation of piece of chromosome ontonormal chromosome
  43. 43. Description  Milder form with some normal cells interspersed with abnormal cells, called mosaic type  Brain weight decreased when compared with normal  Cerebellum and brain stem lighter than normal  Smaller convolutions of cortex
  44. 44. Impairments  Hypotonia  Decreased force generation of muscles  Congenital heart defects  Visual and hearing losses  Atlantoaxial subluxation/dislocation possibly be due to laxity of transverse odontoid ligament  Signsinclude decreased strength, ROM, DTR, and sensation in extremities. This is a medical emergency  Cognitive deficits (mental retardation)
  45. 45. Functional Limitations  Gross motor developmental delay  Difficulties in eating and speech development because of low tone  Forceful neck flexion and rotation activities should be limited due to atlantoaxial ligament laxity  Cognitive and perceptual deficits may result in delay of fine motor and psychosocial development
  46. 46. Interventions & Goals  Minimize gross motor delay  Facilitate gross and fine motor development through appropriate positioning, posture and movement activities  Increase strength and stability by manipulating gravity and resistance in a graded manner  Encourage oral motor function  Facilitate lip closure and tongue retrusion  Short, frequent feeding sessions for energy conservation  Avoid hyperextension of elbows and knees during weight- bearing activities  Prognosis may be correlated with tone; the lower the tone, the more significant the motor delay  All children with Down syndrome will eventually become ambulatory
  47. 47. Duchenne’s Muscular DystrophyA progressive disorder caused by the absence ofthe gene required to produce the muscle proteinsdystrophin and nebulin. Causing cell membranes toweaken and destroy myofibrils and musclecontractility is lost.
  48. 48. Pathology X-linkedrecessive, inherited by boys, carried by recessive gene of mother. Diagnosis confirmed by clinical examination, EMG, muscle biopsy, DNA analysis and blood enzyme levels. Dystropin gene missing results in increased permeability of sarcolemma and destruction of muscle cells Collage, adipose laid down in muscle leading to pseudohypertrophic calf muscles
  49. 49. Impairments Progressive weakness from proximal to distal beginning at 3 years of age to death in late adolescence or early adulthood Positive Gower’s sign because of weak quadriceps and gluteal muscles; child must use upper extremities to “walk up legs” to rise from prone to standing Cardiac tissue also involved Contractures and deformities develop due to muscle imbalance, especially of heel cords and tensor fascia latae, as well as lumbar lordosis and kyphoscoliosis
  50. 50. Functional ImpairmentsDevelopmental milestones may be delayedAmbulation ability will be lost, necessitating use of wheelchair eventuallyProgressive cardiopulmonary limitations
  51. 51. Interventions & GoalsMaintain mobility as long as possibleMaintain AROM/PROM, positioning devices such as prone standers or standing frames. Gastrocnemius and TFL shorten first. Night splints may be used.ES of musclesEducate parents and family in a sensitive mannerDo not exercise at maximal level; may injure muscle tissue (overwork injury)
  52. 52. Brachial Plexus Injury• Traction or compression injury to the unilateral brachial plexus during birth process or due to cervical rib abnormality• Nerve sheath is torn and nerve fibers compressed by hemorrhage and edema, although total avulsion of nerve is possible
  53. 53. 2 Types Erbs Palsy C5-C6, upper arm paralysis may involve rhomboids, levator scapulae, serratus anterior, deltoid, supraspinatus, infraspinatus, biceps brachii, brachioradialis, brachialis, supinator and long extensors of wrist, fingers and thumb Klumpke’s Palsy C8-T1, lower arm paralysis, involves intrinsic muscles of hand, flexors and extensors of wrist and fingers Erb-Klumpke’s Palsy, whole arm paralysis
  54. 54. ImpairmentsSensory deficits of upper extremityParalysis or paresis of upper extremityCharacteristic position for Erb’s palsy of upper extremity is adduction, IR and extension of elbow , pronation of forearm and flexion of wrist
  55. 55. Functional Limitations Dependent on severity of injury  Erb’s palsy results in decreased shoulder girdle function with 1:1 humeroscapular movement  Klumpke’s palsy results in decreased wrist and hand function Traction injuries resolve spontaneously Avulsion injury may require surgical nerve repair if not resolved within three months Shoulder subluxation and contractures of muscles may develop
  56. 56. Interventions & Goals Partial immobilization of limb across upper abdomen for 1-2 weeks to avoid injury Gentle ROM after initial immobilization to avoid contractures Elicit muscle activity with age appropriate functional movements of UE May use gentle constraint of unaffected arm to facilitate use of affected UE Prognosis depends on severity of nerve injury, favorable in most instances, if recovery does not occur, surgery is indicated
  57. 57. Myelodysplasia/Spina Bifida/HydrocephalusNeural tube defect resulting in vertebral and/or spinal cord malformation. Elevated serum or amniotic alpha-fetoprotein, amniotic acetylcholinesterase in prenatal period and sonogram are used for detection
  58. 58. TypesSpina bifida occulta – no spinal cord involvement may be indicated by a tuft of hair, dimple or sinusSpina bifida cystica- visible or open lesion  Meningocele- cyst includes CSF; cord intact  Myelomeningocele- cyst includes CSF and herniated cord tissue
  59. 59. PathologyLink between maternal decreased folic acid, infection, hot tub soaks, and exposure to teratogens such as alcohol and valproic acid to neural tube defects Meningitiscommon if defect not closed soon after birth
  60. 60. PathologyFoot deformities such as talipes equinovarus common, especially with L4, L5 levelTethered cord may lead to increased severity of problems as child growsLatex sensitivity/allergyHydrocephalus significantly related to closure of neural tube defect. Shunting done to relieve pressure of hydrocephalus
  61. 61. Hydrocephalus Abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles inside the brain. Intracranial pressure (ICP) rises if production of CSF exceeds absorption. This occurs if CSF is overproduced, resistance to CSF flow is increased, or venous sinus pressure is increased Congenital hydrocephalus is thought to be caused by a complex interaction of environmental and perhaps genetic factors
  62. 62. Primary Symptoms Acquired hydrocephalus may result from intraventricular hemorrhage, meningitis, head trauma, tumor and cysts Infants may have poor feeding, irritability, reduced activity and/or vomiting Children include a slowing of mental capacity, drowsiness, headaches, neck pain, visual disturbances, and gait disturbances
  63. 63. Impairments Muscleparalysis and imbalance resulting in spinal and lower limb deformities and joint contractures  Kyphoscoliosis  Shortened hip flexors and adductors  Flexed knees  Pronated feet L4,L5lesion results in bowel and bladder dysfunction Sensory loss Developmental delays Abnormal tone- may have low tone which will lead to poor strength and/or spasticity in upper extremities Osteoporosis Cognitive impairments, mental retardation, learning and perceptual disabilities, language disorders
  64. 64. Functional LimitationsWeakness or paralysis of hip flexors (high lumbar level lesion) makes ambulation possible only with reciprocating gait orthosis (RGO)Problems with learning and communication
  65. 65. Interventions and Goals Teach parents proper positioning, handling and exercise, keeping physiological flexion of the newborns, include prone positioning to avoid shortening of hip flexors as well as hip ROM low tone and osteoporosis in mind Use of adaptive equipment/orthoses such as spinal orthoses for alignment, adaptive chairs for sitting (if needed), parapodium for early standing, lower extremity orthoses and ambulation assistive devices and/or wheelchair as needed
  66. 66. Facilitation of functional motor development including appropriate developmental activities, primary or voluntary movement as well as reactive and anticipatory postural adjustmentsEducate parents regarding shunt malfunction, signs include increased irritability, increased muscle tone, seizures, vomiting, bulging fontanels, headache and redness along shunt tract
  67. 67. References:• National Physical Therapy examination review & Study Guide 2011; Susan O’ Sullivan; Raymond Siegelman• PT EXAM the complete Study Guide; Scott M, Gilles• IQ Physical and Occupational Therapy Reviewer• McGraw-Hills NPTE; Mark Dutton