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Peadiatric Rehabilitation -course-book


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While working with the Latika Roy Foundation, I had been training rehabilitation professionals, on various aspects of disability rehabilitation. This course was an attempt to capacity building of rehabilitation professionals in Dehradun. I am a physiotherapist with Post Graduate Diploma in Developmental Therapy and a Public Health professional. I like training and developing professionals in disability and public health. I can be reached at

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Peadiatric Rehabilitation -course-book

  1. 1. LA TIKA ROY FOUNDATION Paediatric Rehabilitation Therapy Course Handbook for interdisciplinary therapy Nalin Kumar (PT) Arju Bala (PT) 16- 27 August 2010 2010 1 4/3A,VASANT VIHAR ENCLAVE,DEHRADUN,UTTARAKHANDCreate PDF files without this message by purchasing novaPDF printer (
  2. 2. 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. 2Create PDF files without this message by purchasing novaPDF printer (
  3. 3. 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 3Create PDF files without this message by purchasing novaPDF printer (
  4. 4. 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 44 VI. ICF 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 85 Tactile Stimulation 18 XI. Neuro Developmental Therapy(NDT) 91 19 XII. Conductive Education 105 20 XIII. Play 106 21 XIV. Biological and Physiological importance of various 108 postures 4Create PDF files without this message by purchasing novaPDF printer (
  5. 5. 22 XV. Wooden furniture/equipments used in therapy 109 23 XVI. Do’s and Don’ts in CP 113 24 XVII. Checklist 115 Chair cum standing frame 25 XVIII. Child Development Worksheet 119 26 XIX. Internet Resources 124 5Create PDF files without this message by purchasing novaPDF printer (
  6. 6. 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 6Create PDF files without this message by purchasing novaPDF printer (
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  8. 8. Concluding Concept: Motor Development Is Age-related but Not Age-dependent References 1. David L. Gallahue, Indiana University, USA 8Create PDF files without this message by purchasing novaPDF printer (
  9. 9. 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) 9Create PDF files without this message by purchasing novaPDF printer (
  10. 10. 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 10Create PDF files without this message by purchasing novaPDF printer (
  11. 11. 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 Hands open Rolls back to side Grasps/holds an object Puts weight on arms while on tummy Hands play at midline Month 4 Sits on propped arm Reaches with both arms/hands Rolls tummy to side Brings fingers/hands in mouth No head lag seen when pulled to sit Squeeze grasp emerging Month 5 Rolls tummy to back Reaches with good aim Wiggles few feet forward Pushes up with arms while on belly Sits propped on hands Month 6 Sits independently for a brief period Reaches precisely and grasps objects Sits in a highchair Transfers toys from hand to hand Rolls over both ways Bangs a cup on a table Month 7 Sits unsupported for ~30 seconds Crosses midline when reaching Rocks on all fours Uses whole hand to rake in objects Pivots in a circle while on tummy Thumb to finger grasp emerging Month 8 Transitions tummy to sit Bangs cubes together Crawls forward Uses a three-fingered grasp Reaches while on tummy 11Create PDF files without this message by purchasing novaPDF printer (
  12. 12. Month 9 Transitions sit to tummy Uses thumb to index finger grasp(crude) Pulls to stand while holding on Crude release of objects Creeps on all fours Drops toys and objects Stands while leaning on furniture Points index finger Month 10 Cruises along furniture Pokes with fingers Stands unsupported briefly Uses thumb to index finger grasp(precise) Transfers from crawl to sit Stacks objects Month 11 Stands unsupported Releases a cube at will Walks with hands held Removes pegs from a pegboard Month 12 First independent steps Puts objects in a container Stands unsupported~12 seconds Releases an object precisely Assumes/maintains kneeling Stacks two one-inch cubes 12-15 Months Walks independently Throws objects Creeps/climbs stairs Places rings on a peg Tries to climb out of highchair Holds large crayon in fisted grasp Squats to play Pulls large popbeads apart Kneels Builds a 2 block tower Stoops and recovers Throws objects References: 1. Harris County Developmental Inventory, Dr. Sears Baby Book, Hawaii Early Learning Profile 2. The Michigan Developmental Scales 12Create PDF files without this message by purchasing novaPDF printer (
  13. 13. GROSS MOTOR DEVELOPMENT MILESTONES IN ALL POSTURES Supine Posture AGE TONE POSTURE MOVEMENT PATTERN / REFLEXES USE OF HANDS MUSCLES 1-3 Head, neck & Keeps head to one side Large, jerky movements in Rooting Starts opening hand from mon trunk: limbs time to time hypotonicity Both arms & legs are flexed, Suckling Limbs: hyper knees apart Arms more active than Starts bringing hand from limbs Grasping side to midline tonicity Sole of feet turn inwards Neck & Head control Hand opening Keep hands closed (fist), thumb starts turn in Flexor withdrawl Movmt. Becomes smooth Extensor thrust & cont. Crossed extension Open hands time to time Tonic Lab. supine Cardinal points 3-6 Head: normal Postural stability of shoulder Kicks strongly Grasp Uses hands for grasp mon girdle Trunk: slight Moves legs alternately Moros Uses both hands, hypotonic Raises head to look at feet occasionally one hand Can roll from side to side Startle Limbs: slight Good head holding Brings hands together hypotonic Can bridge his hips off the Neck righting from sides into midline Starts counterpoising the limbs in surface (5m) the air Primitive squeeze Tries to sit Radial Palmar 6-9 Head: normal Posture stability of pelvis Child holds a leg up in air Raking movt. Try to grasp foot by hand mon in order to grasp his foot Trunk: normal Can lie straight with his hand Startle Manipulate toys Limbs: Can turn his head easily Supine to side lying Moros Begins to point at object with index finger normal Try to sit from side lying Tilt reaction Pass toy from hand to Rolling & rising sequence Saving reaction hand of motion Release toys by dropping 9-12 Normal tone Good postural stability: Very active and controlled Landau’s Puts hands around bottle mon movements of body & when feeding Head & Neck stability limbs Pincer Try to grasp spoon Shoulder stability Pulls himself to sitting Tilt reaction from side lying Clapping 13Create PDF files without this message by purchasing novaPDF printer (
  14. 14. Pelvic stability Turns body to look Saving reaction Drops & throws objects sideways Shake toys to make noise Takes object to mouth less often 12-18 Normal tone Head in center or side (supine As child has learnt to sit, Landau’s Turn pages (thick) of mon position) stand and walk, he/she no books longer prefers supine Pincer Arms/Legs can be flexed or position Feeds himself with extended when in supine Tilt reactions assistance Saving reactions Likes throwing objects one by one 18-24 Normal tone Lie (supine & prone) Functional sitting and Mostly voluntary Can lift objects, throw mon walking movements objects forcefully Sit Movements get more Landau’s Refined grasp and Stand refined scribbling 2-5 Normal tone Use supine position to rest and Use supine position to Voluntary movements Further precision – writing yrs sleep rest and sleep & drawing Fully functional 14Create PDF files without this message by purchasing novaPDF printer (
  15. 15. Prone Posture AGE TONE POSTURE MOVEMENT PATTERN / REFLEXES USE OF HANDS MUSCLES 1-2 Limbs: hyper Neonate: in prone, the baby Reflexive movements. 0-2month- Gallant’s Newborn: the primitive mon tonicity prevails in promptly turns his head Can flex upper limb and trunk incurvation. grasp reflex present. flexor muscles. sideways, his cheeks resting on lower limb with greater the tabletop. The buttocks are suppleness. 1-4 months- 1m. –The reflex is still Head, neck & humped up, with the knees present. trunk: Limited range, a) Cross- extension flexed under the abdomen. The hypotonicity predominantly flexion. reflex. 2m. –The reflex is less arms are close to the chest with prevails / slack / apparent and his hands the elbows fully flexed. Can raise his head to 45 b) Tonic -labyrinthine- are quite often open. no muscular tone. from the plane of the bed. prone. 1month - same with hands under the abdomen and arms & legs c) STNR flexed, elbows away from body, buttocks moderately high. 3-4 Limbs: Lifts head and upper chest wall At 4 months: does 1-4 months- ‘Grasping on contact’, the mon hypertonicity up in midline, using forearms to swimming, flexing and child involuntarily grasps becoming support & (often) actively extending all his limbs. a) Cross- extension an object placed in hypotonicity scratching surface with hands; reflex. contact with his hands. leading to buttocks flat Raises himself on his forearms/ elbows and can b) Tonic -labyrinthine- extension in upper Disassociation of head from raise his head to 45 and prone. limb and lower limb. shoulders; working against 90 from the plane of the c) STNR gravity bed Head and trunk: hypotonicity Strengthening of neck becoming normal. muscles 3mo-2.5 years: Landau’s reflex 5-6 Limbs: normal Placed in prone, lifts head and Lying on his abdomen, he 4-6 months- Righting Lying flat on his abdomen, mon tone. Head chest wall up supporting himself becomes an aeroplane, reactions-Amphibian. the forearms are and trunk: very on flattened palms and extended supporting his weight on hyperextended in front of firm / further arms. his thorax; he raises his the infant and his hands increase in tone. arms and legs. flat on the ground. He Hip-anchoring 3mo-2.5 years: cannot yet use them to Rolls from abdomen to his Landau’s reflex play with but raises back. himself up on hands. Co-contraction of muscles 6 month onwards: Tilt in upper arm reactions (General rule: Concavity on higher side) 7-8 Limbs: normal Placed in prone, lifts head and Easily roles over in both 3mo-2.5 years: Raise one hand from mon tone. Head chest wall up supporting himself directions (back to Landau’s reflex ground to take hold of a and trunk: normal on flattened palms and extended abdomen and abdomen cube. tone. arms. to back). Passes cube from one 15Create PDF files without this message by purchasing novaPDF printer (
  16. 16. Go from complete flexion in hips When lying on his 6 month onwards: Tilt hand to other, bangs to mid-flexion abdomen, he can raise up reaction them together and on the his entire body on his ground. hands and knees. Releases objects 7-12 month onwards: voluntarily with movmt. Four-point kneeling of whole hand. Grasps an object between thumb and little finger. Saving reactions 9-10 Limbs: normal Crawling posture – taking weight Pivots body using limbs to 3mo-2.5 years: Grasp objects between mon tone. Head on hands and knees right/left. Landau’s reflex base of thumb and fore and trunk: normal finger. tone. Achieves sit from hands and The infant tries to crawl knees: Side sitting, W sitting on his stomach & Pulls an object by string. progresses to walking on 6 month onwards: Tilt all fours (hands & knees). reaction Likes to throw objects. He starts by going backwards. 7-12 month onwards: Four-point kneeling Saving reactions 11-12 Limbs: normal Half kneels with hand supports Crawls reciprocally 3mo-2.5 years: Grasp improves further. mon tone. Head Landau’s reflex Can release objects with and trunk: normal Rises to upright kneeling with Bear walk – the infant fine & precise tone. hand supports walks more confidently on Tilt reaction movements. all fours (hands & feet). Bear-walk posture – weight on 4-point kneeling Points to objects with hands and feet forefingers. Saving reactions 15 Limbs: normal Kneels unaided or with slight Inclined crawling- climb 3mo-2.5 years: Makes towers of 2cubes. mont tone. Head support in prone the stairs on all fours. Landau’s reflex hs and trunk: normal Smoothly moving from Turn pages of a picture &abo tone. Half kneels upright no support ext/flex to co- Tilt reaction book. ve (against gravity, extension at the contractions. pelvis) 4-point kneeling Knee walks forward Saving reactions 16Create PDF files without this message by purchasing novaPDF printer (
  17. 17. Sitting Posture AGE TONE POSTURE MOVEMENT PATTERN REFLEXES USE OF HANDS / MUSCLES Neon Limbs: hyper Held sitting – back and head Flexion in total body Grasp reflex Primitive grasp reflex ate tonicity uncontrolled Hand opening Head, neck & trunk: Foot grasp hypotonicity Head righting 2mon Limbs: Held sitting – head remains Head and neck Automatic sitting – Tracking occurs with eye ths hypertonicity upright for few moments but extended but control protraction of shoulder but hand control not becoming wobbles not present girdle present hypotonicity - extension in upper Back – flexed and lower limb. Hips – slight ext. Head and trunk: hypotonicity becoming normal. 3mon Head and neck: Held sitting – head & neck Head & Neck – Labyrinthine head & Clumsy reaching – ths normal tone straight. extended to vertical vestibular righting reflex bilateral Trunk: Back firm but lumbar region still Lumbar kyphosis Grasps objects placed in Hypotonicity weak present hand, thumb adducted Limbs: normal Head control in supine &prone Increased extension of tone position upper and lower limbs 4-6 Tone is normal in Postural fixation of head on Head & neck - Saving & propping Reaching in all directions head, neck, trunk shoulder girdle extended/vertical reactions in forward mont &limbs direction Bilateral to unilateral hs Sitting with support, back Hips extended reach straight, legs straight turning out and apart Legs extended Thumb pressed in opposition Sitting on baby chair with back & Sitting lean on both sides supported or propped on a hands, forward with Ulnar/palmar grasp pillow support less support Wrist flex./ext. 6-7 Tone is normal Postural fixation of trunk on Head, neck – extended Saving & propping Manipulate toys with one mont pelvis reactions in forward hand & use other hand for hs Back – bent to flexion direction support Sitting lean on hands Arms extended Unilateral reach & grasp Lift one hand to play with toys Hips – flexed, abducted Beginning radial grasp & ext rotated 17Create PDF files without this message by purchasing novaPDF printer (
  18. 18. Knees flexed 7-8 Tone is normal Sitting, reach in all directions; Trunk – more control so Saving & propping Use hands to save in mont hand support sideways rotation is possible reactions in sideways forward and side hs direction directions Upper limb – all movements, ext. in one Pats images of face in arm, flex in other mirror Lower limb – Rotation in hip 8-9 Tone is normal Sitting without external support, Head, neck, trunk & Tilt reactions in forward, Manipulation with both mont may use hand for support upper limb – variety of sideways & backward hands (bilateral & hs motions directions unilateral) Lower limb – control Saving & propping improved reactions in sideways direction Full ext. of hip still not possible 9-12 Tone is normal Turn to play, reach, no self hand Co-contraction of neck Tilt reactions in forward, Point with index finger mont support & trunk sideways & backward hs directions Reach and grasp in all Sitting to various positions – Trunk/Pelvic directions round sitting, long sitting, side disassociation Saving & propping sitting, W sitting, cross legged, reactions in sideways Pick & place objects in & stool/chair sitting Hips - anchoring is direction out of large container complete; wt. shifting. rotation Rising out of sitting and getting into all sitting positions 1-5 Tone is normal Various postures can be attained Various muscle Saving reactions Hand manipulation is years activities can be completely developed refined performed because of better control & coordination 18Create PDF files without this message by purchasing novaPDF printer (
  19. 19. Upright Posture AGE TONE POSTURE MOVEMENT PATTERN / REFLEXES USE OF HANDS MUSCLES 0-3 Head, neck & Trunk supported – Plantigrade Hip slight flexion Flexor withdrawl No hand function mont trunk: hypotonic feet hs Knee extension Crossed extension Limbs: Flexor tone in lower limbs, Ankle neutral Placing reaction extensor tone No pelvic stability Automatic walk developing in knees 3-6 Head: normal Bears some weight Hip extension Positive supporting Uses hands for grasp mont (3m) hs Trunk: slight Trunk support is required Knee hyper ext. Uses both hands, hypotonic Negative supporting (3- occasionally one hand Ankle – plantar flex. 5m) Limbs: slight Brings hands together hypotonic Simultaneous contraction Foot grasp from sides into midline of opposing muscle groups started (co- contraction) 6-9 Head: normal Stands with forearm leaning and Hips – both flexors and Placing reaction more Use hands as support mont pelvis support extensors contract predominant while standing hs Trunk: slight simultaneously (co-cont) hypotonic When standing by holding- hips Saving reaction In saving, use hands for may flex, feet are flat Toes flexion protection Limbs: normal 9-12 Normal tone Pulls self to stand Reciprocal contraction of Saving reaction Counterpoising mont opposite muscle hs Cruises using two hands Saving Abduction & adduction of Stands, holds one hand & can hips while cruising Both arms for holding reach in all directions with other Support & bear weight for Can lift one leg cruising 12-18 Normal tone Stands, stoops and recovers Extension of hip, knee, Tilt reaction – trunk Walking – hand for mont ankle (neutral) while support, 2 hand to 1 hand hs Stands without support standing Staggering – forwards, hold sideways, backwards Contraction of hip Carry objects while extensors of one limb & Counterpoising without walking flexors of other limb while holding standing (1 limb) Use hand for rising Simultaneous contract. of Support while stair 19Create PDF files without this message by purchasing novaPDF printer (
  20. 20. flex/ext climbing Abd/flex/ext of hip while staggering 18-24 Normal tone Stand alone, runs Co-contraction of flex/ext Normal Use hands freely for mont manipulating hs Turns (pivots) Reciprocal leg function while running One hand support for (dissociation) climbing Rotation of hip & trunk Can use hands for playing while turning while walking or standing Reciprocal limb movmt. while climbing 2-3 Normal tone Running Symmetrical contraction Normal No support required yrs & relaxation of both limbs Climbing stairs while jumping Use hands simultaneously for manipulation More refined jumping Limb dissociation – reciprocal movmt. of Play-catches ball limbs 3-4 Normal tone Stands on preferred leg, 5-10secs Extension of preferred leg Normal Play yrs Heel to toe stand Flexion of leg More refined counterpoising Dorsiflexion – neutral - plantarflexion Hyperextension in trunk Flex./Add. Of upper limb 4-5 Normal tone Balance on one leg (10sec) Extension and adduction Normal Play yrs of hip Walks on narrow line More refined Counterpoising counterpoising 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. 20Create PDF files without this message by purchasing novaPDF printer (
  21. 21.  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. 21Create PDF files without this message by purchasing novaPDF printer (
  22. 22. 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. 22Create PDF files without this message by purchasing novaPDF printer (
  23. 23. II b. Role of reflexes in development S.No Reflex Normal Stimulus Response Contribution until 1. Sucking 3 mon Introduce finger into Sucking action of lips and jaw Development of oral mouth 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 2 mon a)Touch corner of a) Bottom lip lowers on same side and Helps to locate nipple. points mouth tongue moves towards point of Develops lateralisation of stimulation. When fingers slide away, the tongue. b)center of upper lip head turns to follow. stimulated b) Lip elevates, tongue moves towards c)Center of bottom lip place stimulated. If finger slides along is stroked. 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. 4. Grasp 3 Mon Press finger on Ulnar Fingers flex and grip objects (head in Development of flexor side of palm midline during rest) tone on hand and upper extremities. 5. Hand 1 mon Stroke Ulnar border Automatic opening of the hand. The baby learns extension opening of palm and little movement of finger finger 6. Foot grasp 9 mon Press sole of foot Grasping response of feet Helps baby to grasp the behind the toes surface when held in standing 7. Placing Remains Bring the anterior Child lifts limbs up to step onto table. Helps to place foot in the aspect of foot or hand appropriate position for against the edge of standing and locomotion. table. Ability to place the hand and upper extremity in a position for support in sitting and quadruped position. 8. Primary 2 mon Hold baby upright and Initiates reciprocal flexion and extension It indicates the potential walking tip forwards, sole of of legs. for automatic reciprocal foot press against walking. table. 23Create PDF files without this message by purchasing novaPDF printer (
  24. 24. 9. Galant’s 2 mon Stroke back lateral to Flexion of trunk towards the side of Initiates unilateral trunk trunk the spine. stimulus. mobility. incuvation Creates asymmetrical pattern of movement. Initial movement for rotation initiates amphibian movement necessary for creeping, crawling breaks up symmetrical pattern of movement. 10. Automatic 2 mon Pressure id placed on Child pulls to sitting from supine Weight bearing in Sitting the thighs and the development of standing. head is held in flexion, supine position. 11. Moro 0-6 months Baby supine and back Abduction and extension of arms. Hands Develops extensor tone of head is supported open. This phase is followed by bilaterally in upper above table, drop adduction of arms as if in embrace. extremities and fingers. head backwards, As this reflex matures and associated with loud integrates the upper noise. extremities are prepared for propping and parachute reaction. 12. Startle Remains Obtained by sudden Elbow is flexed (not extended as in Helps as protective loud noise or tapping Moro) and hand remains closed. function. the sternum 13. Landau 3 months to 2 Child held in ventral The head,spine and legs extended. Develops extensor tone in ½ years, suspension, head lift Extended arms and shoulders. the neck musculature of strong 10 the neck to the trunk to months 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 2 months Supine; head mid Uncontrolled flexion response of Helps in protective withdrawal line;legs extended- stimulates leg(do not confuse with reaction. stimulates sole of foot response to tickling) Helps to develop between flexor and extensor tone. 15. Extensor 2 months Supine; head mid Uncontrolled extension of stimulated leg Helps in extensor tone in thrust position, one leg (do not confuse with response of tickling) legs. extended opposite leg flexed-turn head to 24Create PDF files without this message by purchasing novaPDF printer (
  25. 25. one side 16. Crossed 3 months Supine, head , mid Opposite leg adducts, extends, internally Develops alternative extension position, legs rotates, foot planter flexes (typically extensor tone in the lower extended stimulate scissor position). extremities breaks up medial surface of one symmetrical flexion and leg by tapping extension movement, precursor to amphibian movement in preparation for creeping and crawling and walking pattern 17. ATNR 6 Months Baby supine, head in Extension of arm and leg on face side, or Breaks symmetrical mid line, arms and increase in flexor tone. flexion/extension pattern Usually legs extended- turn of movement. Enables pathological head to one side each side of body separately. 18. STNR Rare and 1) Baby is quadruped Arms flex or flexor tone dominates. Helps in creating a usually position or over balance between flexor pathological tester’s knees- and extensors for stable ventroflex the head. position against gravity. 2)Position as above Helps in developing prone dorsiflex the head An arm extendes or extensor tone on elbows to extended dominates; legs flex or flexor tone elbows to 4 foot dominates. quadruped to reciprocal crawling 19. Tonic Pathological Baby supine, head in Extensor tone predominates when the Develops extensor tone Labyrinthine mid position; arms arms and legs are passively flexed throughout body. supine and leg extended, test stimulus is the Creates ability to reach. position. Brings limbs to mid line, cross midline. Free limbs for function away from body, reach, spatial orientation and direction. 20. Tonic 3 months Baby prone; head in Unable to dorsifles head, retract Stimulation of flexor tone Labyrinthine mid position.Test shoulders, extend trunk, arms, legs. of the total body, helps to prone stimulus- prone counter balance the postion. extensor tone in supine. This gives stability to proceed prone development. 21. Positive 3 months Hold baby in standing Increase of extension in legs, planter Helps to develop co- supporting position press down flexion, genu recurvatum may occur. contraction of flexor and the soles of feet extensor necessary for standing. 22. Negative 3-5 months Hold in weight Baby ‘sinks’ ataxia Allows the child for supporting bearing position voluntary weight bearing. 25Create PDF files without this message by purchasing novaPDF printer (
  26. 26. 23. Neck 5 months Supine, rotate head to Body rotates in same direction as the It initiates rolling(Log righting one side, actively or head. rolling) passively 24. Associated pathological Have baby squeeze an Clench of other hand or increase of tone reaction object(with involved in other parts of body. Abnormal side) overflow. 26Create PDF files without this message by purchasing novaPDF printer (
  27. 27. Righting Reactions S.No Reaction Emerges at Stimulus Response Contributions 1. Amphibian 4-6 Months Baby in prone, head in mid Automotive flexion Initiates to attain position, legs extended, lifts outward of hip and quadruped position and pelvis on one side. knee on same side. crawling. 2. Body righting 6- 10 Months If the child rotates hip and Active segmental Dissociation of head and reaction knee (on arm on head reaction. limb occurs which helps in actively) crawling, walking etc. 3. Body righting 4 -6 Months Baby in supine rotate head( Active derotation at 1) Segmental contraction f derotative on one side) Knee on one waist is segmental trunk, neck, hip & leg side rotation of trunk muscles. between shoulders and pelvis. 2) Dissociation of trunk and limb helps in crawling and later walking. 4. Labyrinthine head 2-6 1) Hold the baby Head raises to normal These reactions help to righting vestibular blindfolded in prone in position, face vertical attain antigravity position. righting Months supine, as head drops. mouth horizontal. 2) Hold the baby Head raises to normal blindfolded in supine, in position, face vertical space, as head drops. mouth horizontal. 3) Hold the baby Head rights itself to blindfolded, hold around normal position, face pelvis and tilt it to one side. vertical mouth horizontal. 5. Optical righting 6 Months Hold baby either in supine Head raises t normal Helps to attain antigravity (or in prone, in space as position face vertical posture. head drops) mouth horizontal. 27Create PDF files without this message by purchasing novaPDF printer (
  28. 28. Equilibrium Reaction S.No Reaction Emerges at Stimulus Response Contribute 1. Tilt Reactions 6 Months Baby on tilt board, arms and Lateral curving of head and All the equilibrium legs extended, tilt the board thorax, parachute reaction in reactions are protective. Supine and Prone on one side. limbs accompany trunk They facilitate the body to rotation. maintain various body postures external force and balance in dynamic postures. 2. Four point kneeling 7-12 months Child in Quadruped position a) Lateral curving of head and Do- thorax. a) Tilt towards one side. Abduction extension of arms b) Tilt forwards. and legs on raised side and protective reactions on c)Tilt backwards lowered side may accompany this. b) Forward head and back flexed. Backward-head and back extended. 3. Sitting 9-12 months Baby seated n chair Head and thorax curve, Do- abduction-extension of arms a)Tilt the child to one side and legs on raised side and protective reactions on b) Tilt the child forward. lowered side may accompany this. c) Tilt the child backward. Child extends head and back. a) Child flexes head and back. 4. Kneel standing 18 months Child in kneel sitting position. Head and thorax curve, Do- abduction- extension of arm Tilt to one side and leg on raised side, other protective reaction may accompany this. 5. Standing 12-18 Child in standing position a) Head and thorax curve Do- months abduction extension of arms a)Tilt sideways and leg on raised side, other protective reactions may accompany this. b)Tilt forwards c) Tilt Backwards 28Create PDF files without this message by purchasing novaPDF printer (
  29. 29. 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 29Create PDF files without this message by purchasing novaPDF printer (
  30. 30. 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 30Create PDF files without this message by purchasing novaPDF printer (
  31. 31. 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. 31Create PDF files without this message by purchasing novaPDF printer (