paedriatics neurology

1. COMPONENTS OF NORMAL
AND ABNORMAL MOTOR
DEVELOPMENT

2. •Motor development is directed
by and is dependent upon
1. the maturation of the
nervous system
2. individual genetic coding
3. handling and environmental
experiences (feedback)

3. Development proceeds
•Cephalo-caudally
•From proximal to distal
•From gross movements
to fine movements

4. Motor development is more
correctly called sensory- motor
development
•WHY?
•HOW?

5. •The baby learns the sensations
of movement,
•They are very active that they
repeat movements over and
over developing an awareness
of the sensation of the
movements.

6. In the development of patterns
of motor coordination;
•Muscles are orientated
properly for alignment using
the correct synergies
•There is a great variety of
movements

7. In the development of patterns of
motor coordination, movements are;
• spontaneous
• random
• wide ranges
• automatic
• reinforced by practice and
repetition
• accidental

8. Characteristic of movement
•Every movement involves a weight
shift
•Important to look at and understand
directions and results of weight
shifting.
•Weight shifting provides the
stimulus for Righting Reactions (RR).

9. Characteristic of movement continue
•RR are the automatic background for all
of our movements.
•RR are also the basis for all the more
complex Equilibrium reactions.
•Normal control of the head and trunk
implies the ability to extend in prone,
flexion supine, and laterally flex in
sidelying.

10. ABNORMAL MOTOR DEVELOPMENT

11. Abnormal motor development
•Understanding of abnormal motor
development comes through intimate
knowledge of normal motor
development.
•Starts out along the same process as the
normal does BUT
•many components are missing in the abnormal
process.

12. Abnormal motor development
•Because of missing components;
•baby learns to compensate for
these missing components in the
form of prolonged primitive
movement which become
pathological if not modified by the
development of more advanced
movements.

13. Abnormal motor development
•It is difficult to make definitive
diagnoses of problems early
because;
• early movement problems are
manifested as poor quality of
movement or
•prolonged primitive
compensations.

14. Abnormal motor development
•Knowledge of the subtle components of motor
development and experience make early identification of
possible movement problems easier.
•Milestones of abnormal motor development are
presented as blocks to the normal process of
development.
•A BLOCK is an atypical pattern that occurs when there is
an imbalance btw two muscle groups: this leads to an
inability to stabilize and leads to "fixing" patterns to
compensate for instability. This all leads to atypical
movement patters and decreases in functional mobility.

15. Abnormal motor development
•From the point of the block, the
baby/child must develop
compensations to achieve
movement goals.
•These blocks set the abnormal
motor development process in
progress.

16. Abnormal motor development
•In normal motor development,
•axial extension is the first
antigravity component to be
expressed.
•antigravity flexion in same
proximal areas seems to appear
several months after the extension

17. Abnormal motor development
•In abnormal motor development,
•the antigravity flexion components do not
develop, or
•do not develop sufficiently to counter
balance the extension.
•Leaving baby with abnormal quality of
movement.
•Leading to lack of stability that subsequently
leads to fixing.

18. Abnormal motor development
•Baby learns to FIX (
subcortically learning to hold
himself artificially).
•Fixing prevents further
movement of that segment.

19. Abnormal motor development
•Fixing interferes with the normal
process of simultaneously
•increasing mobility and,
• stability.
•As fixing is used more frequently
and becomes stronger, it blocks the
normal process.

20. BLOCKS IN ABNORMAL MOTOR DEVELOPMENT

21. Motor Development Block
•An atypical pattern that occurs when
there is an imbalance btw two muscle
groups: this leads to an inability to
stabilize and leads to "fixing" patterns to
compensate for instability. This all leads
to atypical movement patters and
decreases in functional mobility.

22. NECK BLOCK – Neck
hyperextension
Normal development
•By 3-4 months child can
•bring and maintain head in midline in
supine and in forearm propping.
•actively tuck chin.
•These elongate head and neck extensor
muscles.
•Combined action of the head and neck is
necessary for the development of head
control.

23. NECK BLOCK – Neck hyperextension
Abnormal development
•Head/neck flexion components do not
develop
•No midline orientation or chin tuck in
supine or forearm propping.
•May push back strongly with head and
neck hyperextension.
•The older CP always lifts his head with
head and neck hyperextension.

24. NECK BLOCK – Neck hyperextension
Compensations
•Elevation of shoulder to stabilize
head
•Shoulder elevation prevents normal
head/neck movements and
exaggerates the hyperextension.

26. NECK BLOCK – Neck hyperextension
Consequences
•Compensations are compounded in
sitting
•Normal scapula mobility is blocked
•They sit with head/neck hyperextension
and no chin tucking leading to opening
of the mouth and eventually to forward
jutting of the jaw

27. Other functional outcomes
•Poor ocular motor control,
•poor neck and UE control,
•decreased grasp,
•reach and manipulation,
•poor bilateral symmetrical motor
control,
•inability to sit,
•forward jutting of the jaw

28. treatment
•Elongate head and neck extensors
while activating neck flexors,
•facilitate active head control in prone
and supine, decrease shoulder
elevation and increase shoulder girdle
mobility/stability,
• facilitate UE stability and mobility,
teach child more normal head/neck
and UE motion in function and play

29. NECK BLOCK – Head & Neck
Asymmetry
Normal development
•By 3-4 months head and neck are brought into
midline symmetry by symmetrical action of neck
flexors.
•Midline orientation of head
-reduces the frequency of stimulation of an ATNR.
-enables visual converge
-enables symmetrical mvts of extremities
-enables hands to come together and onto the body
leading to development of body awareness.

30. NECK BLOCK – Head & Neck
Asymmetry
Abnormal development
•No development of bilateral
symmetrical head and neck flexor
muscle action
• lead to inability to bring or maintain
head in midline.
•dominated by ATNR.

31. NECK BLOCK – Head & Neck
Asymmetry
Compensations
•Dominance by ATNR leads to
-unilateral U.E swiping and reaching.
-difficulty with bilateral symmetrical U.E use
-use of lateral or uncoordinated ocular mvts -
missed the experience of ocular convergence
and coordination which develops with
midline orientation of the head.

32. NECK BLOCK – Head & Neck
Asymmetry
Consequences
•Poor bilateral symmetrical U.E use
•Decreased/poor body awareness
•Poor ocular control therefore poor
visual perception.

33. NECK BLOCK – Head & Neck
Asymmetry
Consequences continue
•Lacks normal hand to mouth play
leading to interference with
normalization of oral sensitivity.
•Persistent head turning (PHT) to one
side sets a stage for
•scoliosis on face side and
•increased risk for dislocation of the hip
on the skull side

34. treatment
•Increase head and cervical spine
mobility, active flexion and midline
orientation of head in supine,
•facilitate symmetrical and bimanual
UE use, bring hands and feet to
midline in supine,
•tactile play

35. SHOULDER BLOCK
Normal development
•There is gradual development of scapula
stability on trunk
•Dynamic scapula stability leads to
•dissociated mvts of humerus
•forearm wt bearing without scapular winging.
• This elongates ms btn the scapula and humerus
and leads to development of shoulder girdle
control.

36. SHOULDER BLOCK
Abnormal development
•Scapular stability does not develop
therefore forearm weight bearing is
not possible or of poor quality(scapular
winging).
•Humerus is “yoked” to scapula, no
dissociated movements ( humeral Ext
R, F and horizontal adduction).
•No development of shoulder girdle
control.

37. SHOULDER BLOCK
•Compensations
•In prone, child uses primitive prone Ext
where scapula adduction is used to reinforce
spinal Ext.
•Or child stabilizes humeri close to his side to
provide additional support for trunk
elevation in prone.
•The compensations further inhibit
development, use, and mobility of sh girdle.

38. SHOULDER BLOCK
Consequences
•No shoulder girdle stability and
mobility,
•poor weight bearing in prone for
crawling.
•Poorly coordinated protective Ext,
reach, grasp and manipulation skills.

39. Other functional outcomes
•delayed fine motor development,
•decreased transitional movements,
tactile sensitivities, decreased
respiration and phonation

40. treatment
•Same as neck hyperextension, improve
scap stability and mobility,
•improve shoulder stability and mobility,
dissociation btw scap and humerus,
•increased wt bearing/shifting in prone-
on-elbows and quadraped, reaching
while in quadraped, tactile play

41. PELVIC-HIP BLOCK
ANTERIOR PELVIC TILT position
description
• Anterior Superior Iliac Spine goes
forward.
• Hyperextension of lumbar spine.
•Hips Flex, abduct and externally
rotate (in prone)  “Frog legged”
position.

42. PELVIC-HIP BLOCK
POSTERIOR PELVIC TILT position
description
• Anterior Superior Iliac Spine goes
back.
• Abdominals (the obliques) Flex,
lumbar area curves or flattens.
•Hips Flex, adduct and externally rotate
in supine.

43. PELVIC-HIP BLOCK - Anterior Pelvic Tilt
Normal development
• Development of active anterior-posterior active movements
• Pelvic movements are accompanied by bilateral LL movements with
controlled mobility of lumbar spine, pelvic and hip joints.
• Lateral weight shifting in prone facilitates:
- Elongation of the weight bearing side.
- Lateral righting of the trunk.
- Lateral hiking of the pelvis.
- Dissociated LL movements.

44. PELVIC-HIP BLOCK - Anterior Pelvic Tilt
Abnormal development
• Development of dissociated movements of pelvis and LL does not
occur.
• No development of abdominals to posteriorly tilt pelvis or balance
and elongate lumbar extensors.
• NB. Lack of development of anti-gravity F in the neck affects
development of anti-gravity F throughout the trunk

45. PELVIC-HIP BLOCK - Anterior Pelvic Tilt
Compensations
•Child maintains the Amphibian
position to prevent lateral weight
shifting in prone  prevents falling
when trying to reach in prone.

46. PELVIC-HIP BLOCK - Anterior Pelvic Tilt
Consequences
• Reduced hip mobility in E, adduction and internal rotation.
• The anterior tilt becomes stronger and tighter = Contracture.
• Child laterally F on weight B. side instead of elongating on trying to
weight shift in prone.

47. PELVIC-HIP BLOCK - Anterior Pelvic Tilt
Consequences continue
• Any changes in hip position are blocked by the frog posture.
• Lordosis in quadruped / 4-point kneeling position.
• -Hip F stabilizes pelvis and hips together.
• Cannot weight shift laterally hence “bunny hops”.

48. PELVIC-HIP BLOCK - Anterior Pelvic Tilt
Consequences continue
• Maintains same posture in kneeling, in standing uses wide base of
support  hip F, adduction and internal rotation, knees adducted,
ankle pronated and everted, toes clawing for stability.
• * Contractures quickly develop with repeated weight B. in this
position.

49. PELVIC-HIP BLOCK - Anterior Pelvic Tilt
Treatment
• Work for mobility and control in all the involved positions i.e. prone,
sitting, 4-point kneeling, kneeling and standing.
• Correct the original problem - poor abdominal activity.
• Only correcting the standing compensations by surgery, stretching or
bracing is useless.

50. PELVIC-HIP BLOCK - Anterior Pelvic Tilt
Treatment
• improve activation of abs, improve mobility in pelvis, hips, knees,
ankles, improve weight shifting in LE WB positions, improve
dissociation of trunk from pelvis, improve LE dissociation of one leg
from another

51. PELVIC - HIP BLOCK-Posterior pelvic tilt
Normal development
• Same as above

52. PELVIC - HIP BLOCK-Posterior pelvic tilt
Abnormal development
• There is a strong lumbar Ext accompanied by hip Ext and adduction in
prone,
• abdominals are inactive.
• Extensor muscles are very tight and not elongated.
• * This demonstrates the cephalo-caudal progress of abnormal anti-
gravity Flexion development observed in the head and neck.

53. PELVIC - HIP BLOCK-Posterior pelvic tilt
Compensations
•Usually not a result of his efforts but
the positions he is placed in because
of tight or shortened muscles.
•Mobility is from points of least
resistance and usually quite
functionless

54. PELVIC - HIP BLOCK-Posterior pelvic tilt
Consequences
• Sacral sitting vs on ischial tuberosities.
• Kyphosis and increased knee F to compensate for tight hip E.
Hamstrings are put on a slack.
• Develop abnormal spinal F, posterior tilt and hip and knee F.
• Hence the older CP child ‘seems’ to have F +++ as the major problem.

55. PELVIC - HIP BLOCK-Posterior pelvic tilt
Consequences continue
• * Sacral sitting is not functional hence “W” sitting.
• Still maintains spinal F and the posterior tilt, has wide base of
support and blocks any lateral weight shift / falling.
• Also ‘bunny hops’ but needs full external support to stand because
adducted LL narrow base of support.

56. PELVIC - HIP BLOCK-Posterior pelvic tilt
Treatment
•Treat with other blocks,
•elongate shortened muscles,
•activate normal counter balancing of
antigravity flexor muscles,
•improve joint mobility with a focus on
hips,
• encourage normal active lateral weight
shifting and normal active lateral righting
response

57. Early identification and intervention
• *Essential because:
• Of the great adaptability and plasticity of the infant’s brain.
• Development proceeds very quickly during the 1st 18 months of the
child’s life.
• To give the child normal sensorimotor experience, before fixing in
pathological motor patterns occurs
(the child will only be able to use what he knows through experience).

58. Early identification and intervention
• * Early intervention by the mother is essential:
- It is easy and realistic.
- Promotes bonding, avoids rejection.
- Prevents parental overprotection.
- Enables carry-over of techniques in the home environment.

59. END