0-12 Months: Motor Development Flashcards
Full term neonate vs. Preterm
physiological FLEXION
full term: physiologic flexion in all positions
flexion caused by utero positioning during last trimester
premature infants lack physiologic flexion
Swaddling
benefits (5)
precautions
- promote physiological flexion- use with PREMATURE infants
- self-CALMING (self regulation) by allowing hand to mouth sucking
- increase proprioceptive and kinesthetic stimulation
- children with lax ligaments do not have good proprioception - increase MIDLINE ORIENTATION
- helps infants sleep better in SUPINE
- AVOID SWADDLING WITH LEGS EXTENDED AND ADDUCTED WHICH CAN CAUSE HIP DISLOCATION
- -can use the Halo Sleepsac (wearable blanket which is safer)
Where do we need elongation for WB
need elongation on the WB side
why do peds need to learn to cross midline
NEED FOR SCHOOL
body and space awareness
work on rotation, copy postures, have them make an x, cross, grapevine
NEONATE
first 28 days
flexor tone diminishes gradually bc HANDLING and GRAVITY
persistent fisting beyond 3 months: suggests hypertonia, UMN lesion
persistent fisting beyond 3 months
RED FLAG
persistent fisting beyond 3 months: suggests hypertonia, UMN lesion
cortical thumb in palm is ok if hand spontaneously opens and no other neurological signs (dont want beyond 7 months)
older children can be DISTAL FIXING because of low tone and weak core–need WB and core strengthening
sign of weak core in children
triangle chest
need abs to pull ribs down
children without abdominal strength
NEONATE:
PRONE
- posture
- hip
- UE
- hands
- where is the weight
- what can the neonate do in terms of motion
- Anterior Tilt
- HIP: Flexion and adduction: prevent pelvis from lying flat
- UE: flexed and Adducted:
close to the body. Some cases arms are under body - HANDS fisted secondary to strong grasp reflex
Weight on face and upper chest
Neonate can lift and turn head to either side
NEONATE:
SUPINE
HEAD
LE
UE
ACTIONS
head:
slightly ROTATED: not enough muscle control to maintain midline
***low tone babies heads are more turned to the side because have more mobility
UE: arms kept close to the body
shoulder: ADDUCTED, ER
elbow: FLEXED
forearm: PRONATED
- (need supination for a good grasp)
hands: may be FISTED or loosely flexed
LE:
hips FLEXED, ABDUCTED, ER
knee FLEXED
ankle DORSIFLEXED
Actions
RANDOM kicking of both LEs: helps to support pelvis. pelvis frequently moves because of the lack of dissociation.
PT pull to sit by UEs: HEAD LAG
FIRST MONTH
SUPINE
- -head
- -neck
- -arms
- -LE
head: TURNS FURTHER TO SIDE
* Neck Righting Reaction: turn head and neck causes the body to follow in a log roll spontaneously –may not occur with low tone babies
arms: no longer close to body: more ABDUCTED
LE: Random kicking
Neck Righting Reaction:
first month supine
turn head and neck causes the body to follow in a log roll spontaneously
–may not occur with low tone babies
FIRST MONTH
PRONE
- -head
- -neck
- -arms
- -LE
UE
more ABducted and ER: moving away from body
LE
hip less flexion, but still flexion: hip flexors elongating enabling pelvis to LOWER
at rest: more LE extended
–hip flexion increases when baby is active such as when lifting and turning head
FIRST MONTH Prone LE review:
what do LE do at rest
what do LE do when active
at rest:
more LE extended
active:
hip flexion increases when baby is active such as when lifting and turning head
Summary 1st Month
follows with eyes TO MIDLINE (not past midline)
more extension: stretch out more
more head and cervical mobility: allow baby to turn head further
prone: baby lifts head and turns to either side
less proximal tightness in shoulders and hips:
- -shoulders ABduct and ER
- hips EXTEND
Infant carrying positions
over shoulder
LE abducted
LE adducted
OVER THE SHOULDER
promotes head extension/head lifting and some rotation (antigravity)
LE ABducted
encourages head rotation
LE ADducted:
in low tone baby the hips are always splayed out into abduction so we want to hold them with hips adducted
SECOND MONTH
summary
visual tracking
head lag
head and body
tone
kicking
(asymmetrical month)
HEAD
visual tracking PAST MIDLINE from side to side
head lag
POSTURE
posture: asymmetry of head and extremities predominates (note relation of head and shoulder)
TONE
more extended: gravity elongating flexors
LE
bilateral symmetrical kicking
SECOND MONTH
prone
HEAD
lift head ASYMMETRICALLY
- -SCM assist upper traps in lifting head
- -HEAD NOT IN MIDLINE
(ATNR)
head may bob when it is lifted
UE
elbows behind shoulders
scapula ADDucted and elevated
THREE MONTHS
Prone
Supine
SYMMETRY and MIDLINE orientation are more dominant
–asymmetry is not uncommon
PRONE: lifts head 45-90 degrees and maintain midline because of bilateral contraction of paired extensor muscles
SUPINE: can turn head side to side and briefly maintain it in midline
ACCIDENTAL ROLLING: prone: head rotates causing weight shifting and then the shoulder girdle collapses and baby rolls to the side
FROG LEG: UE/LE characterized by bilateral abduction and ER: LEs appear frog leg
**BRING HANDS TO THEIR BODY: important in establishing body awareness
Prop on forearms: elbows in line or in front of shoulders
what important thing happens at three months
MIDLINE–can have head in midline
three months: head lifting in prone
- how high
- midline?
- how?
PRONE:
lifts head 45-90 degrees
maintain midline
because of bilateral contraction of paired extensor muscles
ACCIDENTAL ROLLING:
age
how
3 months
prone: head rotates causing weight shifting and then the shoulder girdle collapses and baby rolls to the side
FROG LEG
appearance
3 months old
UE/LE characterized by bilateral abduction and ER: LEs appear frog leg
**BRING HANDS TO THEIR BODY: important in establishing body awareness
Prop on forearms: elbows in line or in front of shoulders
**may persist later in low tone baby
When in prone are elbows in front of or behind shoulders?
2 months: elbows behind shoulders
scapula ADDucted and elevated
3 months: prop on forearms: elbows in line or in front of shoulders because UE/LE characterized by bilateral abduction and ER:
THREE MONTHS
sitting
- pull to sit
- unsupported sitting
- Pull to sit:
–head lag
shoulder elevation and neck hyperextension
[need bilateral symmetrical capital and neck flexors to bring head in midline, antigravity flexors to not have head lag]
- Unsupported sitting: falls forward
head righting noted extends head
scapula adduction to reinforce extension
what does baby need to not have head lag
need bilateral symmetrical capital and neck flexors to bring head in midline, antigravity flexors to not have head lag
Indications for possible disturbances in motor development:
head in midline
WB on forearms
- inability to assume and maintain head in midline: asymmetrical head position causes the infant to WB more on one side
- inability to WB on forearms: baby will not be able to develop ANTIGRAVITY EXTENSION
(if strong ATNR, you cannot break?)
FOUR MONTHS
SUPINE
- head in midline
- tuck chin: chin tuck needed for cervical spine stability –need stability for oral motor control-DROOLING
- bring hands together : hand to trunk and mouth occur because of trunk stability
- -in sitting head goes down to hands because of trunk instability - legs more in line with lower body: increased extension, increased aDduction and less ER. Less frog leg positioning in supine and prone
***low tone babies may maintain frog leg position longer
CHIN TUCK
when develop
why do we need chin tuck?
4 months
need neck balanced flexion and extension for a chin tuck
chin tuck needed for cervical spine stability
need stability for oral motor control-DROOLING
what muscle need in prone on elbows
serratus anterior for prone on elbows
need elongate scapulohumeral muscles
need neck balanced flexors and extensors for a chin tuck
What is chin tuck a sign of?
cervical stability
what does open mouth posture indicate?
congestion and mouth breather because cannot breath through nose ie cleft palate
hypotonia in mouth and open mouth posture
FROG LEG
what can happen if baby cannot break out of frog legged position? (6)
what carrying position do we reccomend
should see less frog leg at 4 months
- interfere with ABDOMINAL CONTROL and UPRIGHT CONTROL: lumbar spine extended, hip flexors tight, pelvis tilted anteriorly
- lack of LATERAL weight shifting: blocks transitions
- interfere with AMBULATION: bc poor LE dissociation
- cannot initiate isolated antigravity knee flexion
- prevent POSTERIOR PELVIC TILT: lack of hip flexion with adduction
- inefficient pelvis stabilization: bc hip abductors remain shortened
**Carrying position to recommend: ADDUCTION
FROG LEG
3 months old
UE/LE characterized by bilateral abduction and ER: LEs appear frog leg
**BRING HANDS TO THEIR BODY: important in establishing body awareness
Prop on forearms: elbows in line or in front of shoulders
**may persist later in low tone baby
Benefit of kicking
who doesnt kick
helps mobilize the pelvis for tilting
low tone baby doesnt do it
FOUR MONTHS
summary
- EYES
- HEAD
- neck
- HANDS
- LE
- eyes move independent of head, eye tracking
- head in midline, tuck chin (cervical stability)
- neck: neck muscles developed enough to allow the infant to sit with support and KEEP HEAD UP
- hands: bring hands together: hands to midline + hand to hand exploration
* **grasp: ulnar grasp
* *bilateral reaching pattern (one arm usually dominant in the reaching) - more anterior and posterior pelvic motions: alternating symmetrical bilateral mass LE flexion and extension kicking affects pelvis.
Extend LE: pelvis anterior tilts
saggital pelvic mobility
FOUR months
hands to trunk and mouth occur because…
trunk stability
in sitting head goes down at 4 months because of trunk instability
What age can infant sit and keep head up
4 months
Extend LE: what does pelvis do
pelvis anterior tilts
What age: eyes move independent of head, eye tracking
4 months
FOUR MONTHS
Grasp
Ulna side of hand to grasp toy–pick up object by using the palm and outside border of the hand
once grabbed the other hand can hold the object
CANNOT TRANSFER TOY FROM HAND TO HAND
- thumb NOT involved in grasp—>therefore baby drops object
- wrist will be flexed: long finger flexors cross the wrist and they are tight
Ulna Grasp
4 MONTHS
GRASPS THE OBJECT WITH THE RING FINGER AND THE LITTLE FINGER AGAINST THE PALM
Ulna side of hand to grasp toy–pick up object by using the palm and outside border of the hand
once grabbed the other hand can hold the object
CANNOT TRANSFER TOY FROM HAND TO HAND
- thumb NOT involved in grasp—>therefore baby drops object
- wrist will be flexed: long finger flexors cross the wrist and they are tight
FOUR MONTHS
reaching pattern
BILATERAL reaching pattern, uses bilateral reaching patterns except one arm usually does the reaching: dominant
FOUR MONTHS
supine
- head
- tuck chin:
- bring hands together
- legs more in line with lower body
**can roll to side-lying via symmetrical flexion (or the primitive method via extension)
- head in midline
- tuck chin: chin tuck needed for cervical spine stability –need stability for oral motor control-DROOLING
- bring hands together : hand to trunk and mouth occur because of trunk stability
- -in sitting head goes down to hands because of trunk instability - legs more in line with lower body: increased extension, increased aDduction and less ER. Less frog leg positioning in supine and prone
***low tone babies may maintain frog leg position longer
FOUR MONTHS
sidelying
—–3 benefits
encourage parents to place infant to side lie for play!!
- New visual and vestibular orientation
- contributes to ribcage shaping–rib cage shaping affected by gravity and oblique muscle pull
- facilitates antigravity lateral head righting –lateral flexion demands balance flexors and extensors
***TORTICOLLIS: put baby into sidelie to work their lateral head flexion
FOUR MONTHS
prone
Prone on Elbows: 5 things
–benefits (3)
Lifts head to 90 degrees in midline
–prone on elbows
1-forearm weightbearing
2-pelvis stabilized
3-UEs out of neonate position -scapulothoracic elongation (elbows under shoulders)
4-chin tuck
5-WS occurs (the direction of the WS supinates the forearm, this lays the foundation for active supination. without supination will not develop grasp. WS is also a prerequisite for reaching)
**no forward reaching–shoulder girdle control will be insufficient to support unilateral WB
- -prone on extended elbows: prepares child for 1. protective reactions
2. reaching
3. quadruped
*have baby reach**no forward reaching–shoulder girdle control will be insufficient to support unilateral WB
MAY SEE ACCIDENTAL ROLLING FROM PRONE TO SIDELYING: weight shift shoulder collapses arm is tucked under, baby rolls
FOUR MONTHS
Rolling: 2 methods
which is preferred?
SUPINE–> SIDELIE
1. roll to sidelie via symmetrical flexion: hips and knees flexed and hands on knees, head rotates (neck righting reaction) trunk rotates to side
- roll to sidelie vs extension: baby uses marked head and neck extension, more primitive method
FLEXION PREFERRED BECAUSE IT STIMULATES LATERAL FLEXION
PRONE–>SIDELIE
***MAY SEE ACCIDENTAL ROLLING FROM PRONE TO SIDELYING:
weight shift shoulder collapses arm is tucked under, baby rolls
FOUR MONTHS
pivot prone
- –what is it part of
- -what muscles used
- -when is it seen
initial phases of Landau (massive extension)
Bilateral Scapular ADuction
seen prior to reaching for a toy
Baby alternates positions: pivot prone and prone on elbows
MAY SEE ACCIDENTAL ROLLING FROM PRONE TO SIDELYING: weight shift shoulder collapses arm is tucked under, baby rolls
FIVE MONTHS
SUPINE
UE (3)
LE (3)
UPPER EXTREMITY
1. can hold bottle
- UNILATERAL REACHING:
objects presented at infants side
unilateral reach across body may cause baby to roll to sidelie - RADIAL PALMAR GRASP: thumb and 2nd and third digits: able to hold object firmly in center of hand
(not yet able to hold with space between object and palm)
LOWER EXTREMITY
1. HAND TO FOOT: pelvic mobility: A/P tilts
both hands to one foot
foot to open mouth
- BRIDGING
- BEGIN TO DISSOCIATE LE MOVEMENT: flex one leg while extending the other
FIVE MONTHS
Rolling
SUPINE–>PRONE
flexion initiates transitions via LATERAL FLEXION/ and EXTENSION completes the roll
- **turn head and roll to side via symmetrical flexion
1. lateral flexion head and trunk (help further into roll)
- bottom arm free, it must ABduct to move out from under the body to assume a forearm weight bearing position (need to WS to get arm free)
- LE dissociate: extend and IR bottom leg
*** baby may stop in sidelie and play: use LE for positional stability, we encourage sidelie play (isntruct parent in sidelie lift)–rib cage development, use extremities differently
FIVE MONTHS
PRONE
HEAD (2)
UE (2)
LE (1)
significance
PRONE ON ELBOWS
HEAD:
- lift head to 90 degrees in midline
- chin tuck
UE
1. forearm weight bearing
- UEs out of neonate position: scapulohumeral
elongation
LE:
1. pelvis stabilized
significance
**weight shift occurs, the direction of the weight shift: supinate forearm: this lays the foundation for active supination
*need supination for grasp
*WS is a precursor for reaching
no forward reaching, shoulder girdle control insufficient to support unilateral WB
FIVE MONTHS
prone on extended arms
what does it prepare child for? (3)
prepares the child for
- Protected reactions
- Reaching
- Quadruped–need extend elbows: if not, do splinting so they can get a feel for what it is like
FIVE MONTHS
activity to do with prone
forward overhead reaching with both hands to grasp a toy
benefit:
scapulohumeral elongation
FIVE MONTHS
lateral head flexion
MUSCLES (2)
REACTIONS STIMULATED (3)
**torticolis: one side not laterally flex –stuck and stuff will suffer
MUSCLES: must have obliques muscle activity to maintain sidelie without rolling.
Must have balanced flexors and extensors
1. oblique abdominals: must stabilize thorax ti allow the head to flex laterally
- quadratus lumborum: laterally flexes the trunk
Reactions stimulated because flex head laterally:
- optical head righting reaction: visual feedback is used to orient eyes with the horizon
- Labyrinthine Righting Reaction: labyrinthine system causes the head to be placed in the proper position against gravity
- Body Righting Reaction on the Head: asymmetrical tactile stimulation to the body causes the head to right itself
FIVE MONTHS
How does optical head righting reaction help with lateral head flexion?
optical head righting reaction: visual feedback is used to orient eyes with the horizon
FIVE MONTHS
How does Labyrinthine Righting Reaction help with lateral head flexion?
labyrinthine system causes the head to be placed in the proper position against gravity
FIVE MONTHS
How does Body Righting Reaction on the Head help with lateral head flexion?
asymmetrical tactile stimulation to the body causes the head to right itself
FIVE MONTHS
Muscles needed to maintain sidelying without rolling
MUSCLES: must have obliques muscle activity to maintain sidelie without rolling.
Must have balanced flexors and extensors
- oblique abdominals: must stabilize thorax ti allow the head to flex laterally
- quadratus lumborum: laterally flexes the trunk
FIVE MONTHS
sidelying
2 benefits
what is needed to achieve it
what muscles needed
BENEFITS
1. asymmetrical proprioceptive and tactile input
- stimulated head righting
POSSIBILITY
**lateral righting possible if balance between flexor and extensors
MUSCLES: must have obliques muscle activity to maintain sidelie without rolling.
Must have balanced flexors and extensors
- oblique abdominals: must stabilize thorax ti allow the head to flex laterally
- quadratus lumborum: laterally flexes the trunk
FIVE MONTHS
Supine–>Sidelying Rolling
roll via extension:
push with LE hyperextends head and trunk
extension reinforced
(slide was missing, something about lacking lateral flexion and LE…)
TYPES OF SITTING
- Propped Sitting
- Ring Sitting
- Half Ring Sitting –begin to dissociate LE (one leg in one posture and the other in another posture-ie one leg in neutral and other in ER and abbduct)
- long sit
- side sit
FIVE MONTHS
Propped Sitting
-how does baby use distal fixing here?
- head
- UE
- LE
when leaning forward baby returns to sitting erect: initially baby will use scapular adduction and thoracic extensions
(distal fixing: using distal shoulder to control proximal extensors)
- Head control: can move head without losing balance
- UE:
bilateral UE support: cannot use UE for play - Trunk/LE:
provides positional stability [hip ABduct, ER] = frog leg in sitting
—–EXTENSORS: inactive trunk and hip extensors, rounded trunk
—–FLEXORS: trunk flexed because of hip flexors
(still need coactivation around the hips, with increasing hip strength and spinal extension baby will sit erect using these muscles for indp sitting)
FIVE MONTHS
Hallmarks @ 5 months
1: hands to knees, hands to feet
What does a baby need in order to sit independently? (that not have at 5 months)
coactivation around the hips
with increasing hip strength and spinal extension baby will sit erect using these muscles
FIVE MONTHS
–what does it mean if forward trunk flexion after 7 months
red flag for poor control of these muscles:
1-abdominal
2-erector spinae
3-hip
abdominal hip extensor tone displace weight posteriorly and the lack of abdominal strength to counteract the pull
need hands free to explore the world
FIVE MONTHS
Rolling
accidental vs volitional
accidental before volitional rolling:
—accidental because have asymmetrical WB head tilted to one side, weak shoulder, not get scapulohumeral elongation
ACCIDENTAL ROLLING:
0-3 months: LOG ROLLING to side
—three months: prone: head rotates causing weight shifting and then the shoulder girdle collapses and baby rolls to the side
VOLITIONAL ROLLING BEGINS 5-6 MONTHS
1. ROLL TO SIDELYING four months: roll to side -roll to sidelie via symmetrical flexion: - roll to sidelie vs extension: - prone-->sidelying
- first: PRONE–>SUPINE
- second: SUPINE–>PRONE
Supine–>prone: flexion initiates transitions via lateral flexion and then extension completes the roll
Supine –> sidelie vis extension
**MUST ROLL BOTH SIDES, IF INFANT DOESNT IT IS A RED FLAG
spasticity can cause stiffness through the trunk, interfering with coordinated rolling movement
Red Flag: infant does not roll over (prone-supine or supine-prone) both to the left and to the right
*MUST ROLL BOTH SIDES, IF INFANT DOESNT IT IS A RED FLAG
spasticity can cause stiffness through the trunk, interfering with coordinated rolling movement
When?
ACCIDENTAL ROLLING:
ACCIDENTAL ROLLING:
0-3 months: LOG ROLLING to side
—three months: prone: head rotates causing weight shifting and then the shoulder girdle collapses and baby rolls to the side
When?
VOLITIONAL ROLLING:
VOLITIONAL ROLLING BEGINS 5-6 MONTHS
1. ROLL TO SIDELYING four months: roll to side -roll to sidelie via symmetrical flexion: - roll to sidelie vs extension: - prone-->sidelying
- first: PRONE–>SUPINE
- second: SUPINE–>PRONE
Supine–>prone: flexion initiates transitions via lateral flexion and then extension completes the roll
Supine –> sidelie vis extension
Order to develop volitional rolling
- roll to sideliying
- prone to supine
- supine to prone
- issue today of less tummy time in prone to develop this
- if they only roll to one direction note it
SIX MONTHS
sitting
UNSUPPORTED RING SITTING
—head rotates: infant falls
- props arms forwards but not sideways
reach in front to play with toy but not to side - LE used for positional stability to prevent lateral weight shift
* **Bilateral ABduct and ER block weight shifting
RING SITTING
when
position
pros (1)
cons (3)
when: SIX MONTHS: unsupported ring sitting
position:
1. LE used for positional stability to prevent lateral weight shift
* **Bilateral ABduct and ER block weight shifting
- high guard arm positioning: scapula ADduction
PROS:
1. stable:
— cannot laterally weight shift
free arms for play!
CONS:
1. props arms forwards but not sideways
reach in front to play with toy but not to side
- If used exclusively: contributes to tightness in hip flexors, ABductors, ERs, and Hamstrings
- difficult to transition out of ring sitting
***older infants revert to ring sitting when engaging in a fine motor task
When do older infants revert to ring sitting ?
older infants revert to ring sitting when engaging in a fine motor task
SIX MONTHS
pivot prone
- –what is it in development
- –what is a pro
- –what is it alternated with
4-6 months
mature Landau
prone is a functional position
alternate this with prone on extended arms
SIX MONTHS
how does baby move around in pivot prone
uses this to get toys
TURNING: pivoting in prone–pivots in a circle: head and trunk in lateral flexion:
- skull side arm pushes
- face side arm to reach
FORWARD AND BACK: bilateral symmetrical pushing causes the baby to slide forward and back
*weight shift for reaching
(difficulty may be due to: weakness, inability to weight shift, tonal disturbances)
Atypical Pivoting in Prone
- asymmetrical: infant rotates to only one side
- fails to use other forms of locomotion by 9 MONTHS—should be doing quadruped
- difficulty may be due to:
- – weakness
- – inability to weight shift
- – tonal disturbances (incr/decr)
Need WS, Elongate and Shorten sides
need lateral flex one side and elongate the other sides
**torticolis:
**brachial plexus injury
Difficulty moving in pivot prone may be due to (3)
difficulty may be due to:
- – weakness
- – inability to weight shift
- – tonal disturbances (incr/decr)
SIX MONTHS
Standing
- FULL WEIGHT BEAR at 6 months (bear partial weight at 5 months) –wont drop to the floor
- Hips and knees FLEXED
- feet PRONATED–fat pad at longitudinal arch and not develop ankle yet
- may bounce
SIX MONTHS
Fine Motor (4)
- finger feeds
- palmar grasp
- transfer toys hand to hand
- shakes and bangs toys
What may be problem that child cannot sit independently (5)
7-9 months!!!
- low tone
- poor trunk extension
- tight hip extensors causes child to fall backwards
- instability of pelvic/femoral:
weak hip extensors: baby must lean forward and prop
SEVEN MONTHS
Supine
- Roll: supine –> prone
- lifts head more :
antigravity flexor control: must have obliques muscle activity to lower and stabilize rib so that the head can move - strong lateral flexion
will prefer PRONE because it is more functional
if prefers supine then further observation is needed
SEVEN MONTHS
does baby prefer prone or supine
red flags
will prefer prone because it is more functional
if prefers supine then further observation is needed
SEVEN MONTHS
PRONE
prone is functional and allows mobility
transitions prone –> quadruped
heavy babies stay on their bellies longer and do not assume quadruped as soon (not enough strength to push up)
low tone babies frequently have difficulty assuming quadruped (lack stability)
SEVEN MONTHS
What babies have difficulty assuming quadruped ?
heavy babies stay on their bellies longer and do not assume quadruped as soon (not enough strength to push up)
low tone babies frequently have difficulty assuming quadruped (lack stability)
SEVEN MONTHS
Quadruped
7-9 months
- co-contraction of hip musculature for stability around hip joints
- LE positioning to accept weight: KNEES ARE UNDER HIP.
[low tone child knees are not under hip. discourage carrying over mothers hip, consider hip helpers to avoid abduction] - Flat back because lumbar spine is stabilized: balanced musculature
SEVEN MONTHS
Quadruped: KNEES UNDER HIP
- -what child won do this
- how should mothers not carry child
- what should be used for position to avoid a position to prevent issue here
7-9 months
LE positioning to accept weight: KNEES ARE UNDER HIP.
*work to extend hip to get the knees behind the hip, need stable core to do that, if they do not do it is a compensation for a weak core
low tone child knees are not under hip
—discourage carrying over mothers hip
—consider hip helpers to avoid abduction
SEVEN MONTHS
Babies that have problems with Quadruped
7-9 months
- baby’s size
- Poor UE weight bearing
- Poor UE weight shifting
- poor LE dissociation
- excessive hip mobility, poor pelvic control
- poor trunk control
first assume quadruped anterior pelvic tilt: DF ankles
as abdominals and hip extensors increase control they modify the pelvic position
SEVEN MONTHS
how is quadruped different when increase abdominal and hip extensor control?
7-9 months
first assume quadruped anterior pelvic tilt: DF ankles
as abdominals and hip extensors increase control they modify the pelvic position
SEVEN MONTHS
Immature Quadruped Position
- -how may the muscles be affecting an incorrect quadruped position?
- -knee not under hip (2)
- -lumbar lordosis (2)
7-9 months
Knee not under hip
hip ABduct and ER: LE in poor WB position: knee not under the hip
overactive hip flexion
lumbar lordosis:
- –indicates weak abdominal, or inactive abdominal
- –overactive hip flexors: to stabilize the hip anteriorly tilting the pelvis causing a lordosis
SEVEN MONTHS
What are “hip helpers”?
prevent hip abduction, splaying of the hips
support shorts to limit excess hip abduction in babies and toddlers with low muscle tone to improve rotational movements
—low tone seen in Downs syndrome, hypotonia
[excess mobility will interfere with assuming quadruped position]
LIMITS “W” SIT
SEVEN MONTHS
Quadruped
7-9 months
rocking
rocking forwards and backwards helps develop hip joint stability
rock forwards and backwards: must be stable to rock
as control increases lateral (Z) and diagonal (Y): weight shifting occurs
encourage
assume–> maintain –> rock–>reach
SEVEN MONTHS
order of movement developing axes
sagital –> frontal –> transverse rotation
need x and z to get rotation
SEVEN MONTHS
Quadruped progression to encourage
7-9 months
assume position –> maintain position –> rock–>reaching
SEVEN MONTHS
crawling (not complete) = bunny hopping
bunny hopping [uses extended arms and pulls with flexed hips and knees]
uses bilateral symmetrical LE and UE movements
used because:
1. cannot lateral WS
- no LE dissociation
- no diagonal trunk control (need to reach forward with arm and contralateral leg to crawl normally)
SPASTIC DIPLEGIA
pediatric immobilizers–why we would use them
to encourage weight bearing on the involved UE during play in quadruped
then moving on to creeping
EIGHT MONTHS
!!!!!!INDEPENDENT SITTING!!!!!!!!!
7-9 months
sit functional: independent sitting
- -may use positional stability (frog leg, ring sit)
- -beginning to use a variety of sitting positions
RED flag: IF NOT SITTING INDEPENDENTLY
EIGHT MONTHS
RED FLAG
RED FLAG:
NOT SITTING INDEPENDENTLY
EIGHT MONTHS
Pull to stand: early attempts (4 motions to do it)
Sitting Down
pull to stand (may see at 7 months)
early attempts (may first begin in the crib):
- fix pelvis into anterior pelvic tilt
- primarily uses UEs: places arms on surface and pushes down or pulls with the arms to rise to stand
- then forward weight shift
- uses symmetrical LE extension to assist
***DOES NOT KNOW HOW TO SIT: FALLS TO SIT DOWN
10-12 MONTHS
PULL TO STAND (2)
–what indicates more stability
- uses LE more actively than he did at 8 months!!
lateral WS: flexes non weight-bearing hip and places foot on the floor (1/2 kneeling, proposal) - uses UE for balance (not for the motion to happen)
- as stability improves using one hand and pulls up on less stable objects
- Improved stability: go from gripping to palming the surface with an open palm
10-12 MONTHS
Stand–>Sit
–what it requires
Squats: quadriceps eccentrically contracting
—-without eccentric quad control will fall: work on graded knee control: picking up toys from different surfaces
(without this control on stairs they do step to pattern and when running they do a gallop run if lack midrange control and keep knees stiff)
May drop Toys down to practice lowering self
10-12 MONTHS
Bear Walking
–what it requires (5)
- stable shoulder girdle
- activate abdominals (look for ripples to see contractions)
- LE mobility
- feet must PUSH against the floor (not pull)
- elongates hamstrings and gastroc (need
extension)
good position to work towards and in for infants with movement difficulties especially high tone and low tone
NINE MONTHS
side-sit
side sit at 9 months (sitting with one leg like a w sit and the other leg like a half ring sit)
- axial rotation
- elongation of the trunk on the WB side
- lumbar extension
- LE dissociation:
one hip ER and ABduct
other hip IR and ADduct
A COMBINATION OF RING SITTING AND “W” SITTING
“W” Sitting
-what is it associated with
W sitting is a normal sitting position, typical if it is part of a variety of sitting postures
***IF USED EXCLUSIVELY: leads to decreased control of trunk and hips
- associated with low tone (posterior pelvic tilt)
- -no pelvic rotation and no lateral weight shifting: trunk muscles are not challenged,
- - W sitters lack trunk and pelvic stability
- -using LE posturing for stability rather than muscle activity to stabilize the pelvis
- -if used exclusively leads to decreased control of trunk and hips - reinforces femoral anteversion: femoral anteversion associated with toe-in gait
**if a child has hip dysplasia the extremes of internal rotation could put the child at risk for dislocation
- stretches the MCL of the knee: later may contribute to genu valgum: knock knee position in standing
- associated later in life with developing a SWAY BACK POSTURE
W sit: low tone
W sit associated with low tone (posterior pelvic tilt)
- no pelvic rotation and no lateral weight shifting: trunk muscles are not challenged,
- children who use W sit all the time lack trunk and pelvic stability
- using LE posturing for stability rather than muscle activity to stabilize the pelvis
–if used exclusively leads to decreased control of trunk and hips
Effect of W Sit on the Femur
reinforces femoral anteversion: femoral anteversion associated with toe-in gait
**if a child has hip dysplasia the extremes of internal rotation could put the child at risk for dislocation
Effect of W sit on the knee
stretch MCL
later may contribute to genu valgum: knock knee position in standing
Effect of W sit on trunk and hips
***IF USED EXCLUSIVELY: leads to decreased control of trunk and hips
TALL KNEELING
10-12 Months
–which muscles
without UE support:
- quadriceps contract to elevate the body
- hip extensors stabilize trunk
- **if hip flexors are used to stabilize–slight anterior pelvic tilt and DF
maintain hip flexion, ABduction and ER
–if strong hip flexor contraction: anterior pelvic tilt and DF
difficult for baby to extend hips in kneeling: rectus femoris is tight, gluteus maximus is weak
Cruising
what it requires (3)
what we may see and why (2)
what strength it builds up
SIDESTEPPING: so that pelvis does not have to rotate
REQUIRES
1. Hip ABduction and hip ADduction control
- UE stability
- LE weight shift
WHAT WE MAY SEE
1. toe curling to increase stability (distal fixing for proximal stability)
- shoulder elevation to increase postural stability
***BUILDS UP HIP ABDUCTOR STRENGTH
STANDING
11-14 months
arms used for stability
- Bilateral–if not then places trunk on the surface
- As stability increases diagonally turns away and supports self with one UE
- may take first step without UE support when reaching to another surface
less hip and knee flexion
raise up on toes in picture
Supported Walking
10-12 Months
shoulder
pelvis
hips
ankle
foot
two hands held–>one hand held
SHOULDER
fixing: scapula adduction: facilitates spinal extension
PELVIC
Anterior pelvic tilt
HIPS
hip ABduction and ER: wide BOS: in stance and in swing phase of gait
ANKLE:
everted heels
FOOT:
***NO HEEL STRIKE
Early Gait Characteristics
STABILITY (4)
indp gait at 10-15 months
- wide BOS: hips ABducted and ER (toe out)
- Thoracolumbar extension to control the forward displacement of the body (need to align ribs over pelvis to facilitate abdominals)
- Oral mechanism contributes to head, neck and shoulder stability
- UE fixing: to stabilize shoulder girdle and upper trunk
mature gait: age 3
When see mature gait characteristic
age 3 years
Early Gait Characteristics
WS
UE
HIP
KNEE
ANKLE
Lateral Weight Shift through displacement of the head and shoulders and upper body
UE:
- if walking to parent: shoulders flexed and outstretched
- stabilizing fixing: HIGH GUARD positioning arms move in and out of fixing pattern –one arm may be at side then with the next step in stabilizing position
- NO RECIPROCAL ARMSWING
HIP
1.excessive hip flexion throughout the entire gait cycle
- hip extension varies to absent at terminal stance to a few degrees prior to toe off
- hip ER throughout entire gait cycle: toe out
KNEE
1. knee flexed through midstance with very early walkers gradually it is reduced and knee extension increases
ANKLE
1. new walkers have absent heelstrike: go straight into footflat contact: or PF contact
- relative footdrop in swing phase
- PLANTAR FAT PAD: pronation
(disappear at age 2 years and longitudinal arch becomes visible)
81 minutes in prone
infants spending 81 minutes in prone achieve greater success in acquiring:
prone, supine and sitting milestones comparing to those infants that spend less time
(infants tend to spend most time in supine)
FIXING
why is it used
it is used to decrease the degrees of freedom at a joint
can occur when a child is learning a new skill
can be used for stability and to control movement.
*lack of head control: neck hyperextension and shoulder girdle elevation in sitting is compensated for poor postural stability
ATYPICAL (6)
0-2 Months
1-strong extension 2-unable to lift head in prone 3-no WB in supported standing 4-no kicking 5-strong asymmetrical postures 6-hypotonia
ATYPICAL (4)
3 months
1) SUPINE: minimal kicking
2) no hands on body exploration
3) unable to lift head
4) no attempt to lift head when pull to sit
Atypical (6)
4 months
1) poor MIDLINE orientation of head and hands
2) unilateral UE use
3) prone unable to LIFT HEAD
4) pull to sit, no assist with HEAD LIFT
5) unable to RING SIT
6) no WB in supported standing
Atypical (5)
5 months
1) supine: no hands to feet or foot to mouth, poor midline orientation
2) rolls to side via extension
3) sidelie: no lateral flexion, no LE dissociation
4 )cannot ring sit
5) no WB or extension in standing
Atypical (3)
6 months
1) prone: maintains frog leg position, no UE WB
2) pull to sit: head lag, shoulder elevation (traps instead), no initiation
3) standing: WB on toes, LE extended
Atypical (5)
7 months
1) supine: prefers supine
2) prone: not reaching in all directions for toys
3) sitting: independent ring sit only, cannot transition in/out of sitting
4) quadruped: bunny hop
5) standing: no WB or weightshifting, heels not on floor
Atypical (3)
8-10 Months
1) sitting: “w” or ring only, no transitions in or out, cannot sit independently
2) crawl: bunny hop or no crawling, cannot climb on furniture, scooting on butt
3) standing: weight on toes, unable to weight-shift, unable to reach for or play with toy
Atypical (3)
11 Months
- in addition to what was mentioned
1) no cruising
2) no forward walking with hands held
3) commando crawling
4 observable stages of postural control
- LOWEST LEVEL OF POSTURAL CONTROL: infant falls to stop a movement
- infant will extend and abduct arms or legs to stop a fall (increase BOS)
- lateral righting reaction of the trunk to stop a movement or prevent a fall
- MATURE LEVEL OF POSTURAL CONTROL:: equilibrium reactions to stop a movement or a fall–balance of extensors and flexors: lateral and diagonal movements
protective response
- purpose
- what movements of limbs
- in standing
- in sitting
- when impaired?
PURPOSE: regain balance when center of mass has been pushed beyond base of support
movements are in FRONTAL and SAGITTAL planes: aBduction and extension of arms or legs to stop the fall
in standing: stepping strategy
in sitting: forward/ lateral/ posterior protective are used
***IMPAIRED WITH hemiparesis, CMT (torticollis), brachial plexus injury
equilibrium reactions
infant is tilted slowly off balance, he automatically moves his head, trunk, and limbs in the opposite direction of the tilt to maintain balance
developmental sequence
6 months: prone
8 months: supine, sitting
10-12 months: quadruped
12-21 months: standing
equilibrium reactions
–positive if
positive if head and trunk righting occurs away from the weight shift
am and leg opposite the weight shift abduct
trunk rotates: curves their trunk in the opposite direction of the tilt to maintain balance
Speech and Language (3)
0-3 months
Hearing and understanding
1) Startles to loud sounds
2) quiets or smiles when spoken to
3) in response to sound: increase or decrease in sucking
Speech and Language (3)
0-3 months
Talking
1) cooing and gooing sounds
2) cries differently for different needs
3) smiles when sees you
- concerning if not making sounds
- should smile back
Speech and Language (3)
4-6 months
Hearing and Understanding
1) eyes move in direction of sound (tracks sound)
2) notice toys that make sounds
3) pays attention to music
Speech and Language (4)
4-6 months
Talking
1) babbling
2) laughs
3) vocalizes excitement and displeasure
4) makes gurgling sounds
Speech and Language (3)
7 months-1 year
Hearing and Understanding
1) likes peek-a-boo
2) turns and looks in direction of sound
3) understands simple instructions; begins to respond to requests (ie come here or want more)
* social interactions
Speech and Language
7 months-1 year
Talking
1) uses gestures to communicate
2) 1-2 words (hi, dog, dada, mama)
may not be clear
3) uses speech or non crying sounds to get attention
* concern frustrated if always cries to get attention because cannot communicate
RED FLAG/Clinical Signs exist to help identify children at risk for language delay and/or ASD
language delay
autism (ASD = autistic section disorder)
1) ANY LOSS OF SPEECH, BABBLING, OR SOCIAL SKILLS AT ANY AGE
BY 12 MONTHS
2) no babbling by 12 months old
3) no back and forth gestures as pointing, showing, reaching, waving by 12 months
BY 16 MONTHS
4) no words by 16 months
BY 24 MONTHS
5) no 2 word meaningful phrases (does not include imitation or repetition) by 24 months
Baby Sign Language
pre-verbal
teaches:
1. joint attention
2. sign and use the word for the action
3. hand over hand to create the sign
4. imitates the sign look for approximation
