Week 6

Question 1

What is the gross milestone of mobility (5-6 yr)?

Answer 1

can stop, change directions quickly, hop 8-10 steps on 1 foot, roller skates, rides bike, skips

Question 2

What is the gross milestone of mobility (8 yr)?

Answer 2

jumps rope well, throws ball with improving accuracy (10+ft)

Question 3

What is the gross milestone of mobility (7 yr)?

Answer 3

Mature walking

Question 4

What is the gross milestone of mobility (10-12 yr)?

Answer 4

jumping distances increases, running speed stabilizes for girls, improved reaction time allows for improved performance in sports.

Question 5

What is the fine motor milestone (5-6 yr)?

Answer 5

More mature pencil grasp (dynamic tripod: look back at the grasp pictures), ties shoes, zips up coat independently, copies a diamond correctly

Question 6

What is the fine motor milestone (7-9 yr)?

Answer 6

continues to refine dexterity, improved reaction time, begins to play games that require improved fine motor skills, may develop hobbies that require highly refined fine motor coordination e.g. sewing, model building.

Question 7

What is the social emotional milestone (5 yr)?

Answer 7

Self control is still less than ideal, success depends on removal of temptation or redirection/diversion

Question 8

What is the social emotional milestone (6 yr)?

Answer 8

Struggles with ambiguity, has difficulty understanding/detecting intentions where damage occurs

Question 9

What is the social emotional milestone (7 yr)?

Answer 9

May express two emotions about the same situation, but they will be related/similar, begins to understand gender constructs more concretely (Academy of pediatrics says 4…..maybe we need more research?). Personality, the things about you that make you who you are, are generally established by 6-7 years of age.

Question 10

What is the social emotional milestone (8-9 yr)?

Answer 10

Understands that two people can feel differently about the same situation, but thinks this is just due to different info.

Question 11

What is the social emotional milestone (10-11 yr)?

Answer 11

Able to objectively look at own view and another’s view, has trouble detecting deception, time with friends vs family begins to significantly increase.

Question 12

Which stage of Piaget’s stages of play persists into early “school age”?

Answer 12

Symbolic play

Question 13

Describe Rule Play

Answer 13

(5-7 yr+) (cooperative & competitive)
◦ Involves more than 1 child, and rules are formulated through social conventions and interactions
◦ Cooperative play
◦ Toys are shared and there are simple organized games. All participating know the goal of the game and can switch roles. Examples include tag, chase, and catch.
◦ Competitive play
◦ Involves progressively more complex organized games all the way to regulation team sports.
◦ Progression in movement activities demanding self competition, individual competition, or group competition.
◦ Self competition-you compete against your best performance; examples include juggling, standing on one foot, shooting baskets.
◦ Individual/dual competition-one person is competing against an opponent- track, swimming, tennis or involves having a partner; such as bowling, doubles tennis
◦ Group competition-cooperation among the group is a necessity. One must cooperate with team members while concurrently competing with
opponents.
◦ Many educators feel that competition should not be introduced until 3rd grade due to the social characteristics of children rather than motor skills or rule knowledge. It is also believed that too much time spent on one sport deprives a person of experiences needed to understand and appreciate one’s own body and its capacity for a variety of movements.

Question 14

What is the cognitive language milestone (5-6 yr)?

Answer 14

Understands past, present, future concepts, begins to use concrete operational (Piaget) thinking, begins to use invented spellings, grammar becomes more adult-like, understands jokes based on phonological ambiguity.

Conservation of mass (ex: if a chocolate bar is cut in half, the child thinks it is not the full bar anymore)

Question 15

What is the cognitive language milestone (7-8 yr)?

Answer 15

Understands conservation of mass, begins to use rehearsal strategies to aid memory, plays strategy games, begins reading for pleasure, begins to understand subtle differences between “ask” and “tell”, more conventional spellings

Question 16

What is the cognitive language milestone (9-10 yr)?

Answer 16

“ask” and “tell” differences consistently understood and used, spelling continues to improve in sophistication, judgments about text relevance improve, ability to accurately summarize emerging.

Question 17

What is the cognitive language milestone (11-12 yr)?

Answer 17

Shows skill in summarizing and outlining content, appreciates more complex jokes based on syntactic ambiguity, Formal operations (Piaget)

◦Child develops abstract thinking. When faced with hypothetical situations, they will use deductive
reasoning

Question 18

What can an IQ test identify?

Answer 18

IQ=MA/CA x 100
◦Mental age (IQ test score)/ Chronological Age x 100
◦May help to identify an ‘at risk’ child and provide rationale for early intervention; get the child the supports to hope that s/he improves with these supports. More on this in a moment

Question 19

What are some pros of IQ tests?

Answer 19

• It is measurable
• It is innate and is not altered by the environment
• IQ scores can be predictive of a person’s abilities/performance in the future (i.e. in school)

Question 20

What are were IQ tests historically used for?

Answer 20

IQ tests were historically used to evaluate immigrants or to determine eligibility for the armed forces. One of the early uses of IQ tests was to “assess” non-English speakers’ intelligence; when these non-English speakers failed a test administered in English, they were labeled as ID (intellectually disabled). They typically did not get further assistance or job training, and some were institutionalized. As you can see, even the data gathered from this “low risk” test can be used to make very high stakes conclusions.

Question 21

What are some cons of IQ tests?

Answer 21

• MA (mental age) increases until mid teens to 20’s, then plateaus, so if there is an increase in age (CA), IQ appears
  to decrease.
• Use just one score to reflect a variety of abilities
• Fails to address creativity (non-academic skills)
• Does not consider culture
• Performance can be affected by motivation, practice and educational experience
• Does not address language differences, reading problems or non-verbal issues
• Does not assess skills/knowledge in infants or children under 4 years old. In other words, IQ tests are not reliable
  in children under 4 years of age and should not be used on such young children.
• And what about environmental factors? (Dynamic systems theory remember? It matters!!)

Question 22

What is the importance of Skeels and Dye Study?

Answer 22

In the 1930s, researchers H.M. Skeels and H.B. Dye moved 13 orphaned children (experimental group) to live with older women with intellectual disabilities, while 12 children (control group) remained in the orphanage. Over two years, all children were tested before and after the experiment. The experimental group’s IQ increased by an average of 27 points due to attention and stimulation, while the control group’s IQ dropped by 26 points. A follow-up study 21 years later showed that all 13 in the experimental group were self-supporting, with none institutionalized, and had completed an average of 12th grade. In contrast, 4 of the 12 controls were institutionalized, and their median education level was 3rd grade. These results highlight that even minimal enrichment can significantly benefit child development.

Question 23

Describe Wolff’s Law

Answer 23

bones develop in relation to the forces that are placed on them. Those forces occur from loading during weight bearing and pull of muscles through activation. The result is external and internal changes in the bone. Bones become stronger if they are loaded (hypertrophy) and can become weaker resulting in a decrease in bone strength (atrophy) if they are not properly loaded.

Question 24

Describe Heuter-Volkmann Principle

Answer 24

Growth plates located at the end of bones, produce growth in response to tension and decrease growth in response to excessive compression

Question 25

What is a unique trait of bone remodeling in infants?

Answer 25

(Bone remodeling in infants is 10 times the rate of an adult) (need to move for the remodeling of the bone)

It is critical to be able to recognize normal MSK and alignment issues in children and how they can be affected by pathologies and impact adult development

Question 26

What is a noticeable biomechanical trait in infants?

Answer 26

Infant in the beginning: Flexion is king

Flexion is still present even in supine, but to a lesser degree due to gravity and the affect of the tonic labyrinthine supine reflex

(Does not have knee terminal extension, hip extension)

Question 27

Describe the biomechanics in this picture

Answer 27

Physiological Flexion-Sitting:
* Spine is kyphotic (spinous processes are nearly horizontal rather than having the curve noted in the adult)
* Low back is in flexion.
* There is a posterior tilt of the pelvis
* The acetabulum is in a retroverted position, meaning it is facing slightly
backwards. This is normal, I’ll show you a picture in a moment.

The sacrum is not fully fused until the end of the first year of life.

Question 28

Describe the biomechanics of the hip

Answer 28

*There is a flexion contracture of at least 30 degrees. There is no true hip extension until 2 years of age.
*The position is held due to muscular contracture of iliopsoas muscle and shortened anterior hip joint capsule
*There is more external rotation (90º) than internal rotation(60º)
*The acetabulum is shallow (increasing the risk for dislocations) and has a downward inclination
*The neck of the femur is in a position coxa valga -which is an increase in the femoral neck-shaft angle from 125º to 150º. This neck-shaft angle is known as the angle of inclination.
*This angle should be ~125 degrees in an adult. Too much coxa valga can result in hip dislocations. Swaddling a baby very tightly can cause increased pressure on the femoral neck increasing the neck shaft angle (increasing coxa valga) and increasing risk for dislocation of the hip. The angle of inclination decreases gradually from birth and is at it’s mature value around the end of the sixth year.

Question 29

What is the angle of inclination and angle of rotation for the femoral head to femoral condyle angle in an infant?

Answer 29

Angle of inclination: 135-145 degree

Femoral head to femoral condyle angle: 25-30 degrees

(Weight bearing through their legs, combined with the increased gluteal activation during mobility with cause the angle between the femoral neck and condyles to decrease into the typical adult range of 10-15 degrees.)
(Anteversion in infants but lowers to normal as they get older)

Question 30

Label

Answer 30

A) normal femoral neck shaft angle
B) coxa vara (less than 120 degrees)
C) coxa valga (more than 135 degrees)

Question 31

Describe

Answer 31

(Transverse angles)

A) normal hip

B) femoral anteversion: “in toeing” “pigeon towing” if the body can’t compensate. The move is compensated by externally rotating but if it is too far (functional weakness and glute lengthening)

C) femoral retroversion: “out toeing” “duck footing” if the body can’t compensate. The move is compensated by internally rotating but if it is too far then (functional weakness and glute shortening)

Question 32

Is retroversion abnormal?

Answer 32

Yes, all the time

Question 33

Label

Answer 33

1) newborn (moderate genu varum)
2) 6 months (minimal genu varum)
3) 1-2 years (legs straight)

Question 34

Label

Answer 34

1) 2-4 year (physiologic genu valgum)
2) 16-year-old females (slight genu valgum)
3) 16-year-old males (slight genu varum)

Question 35

Describe knee biomechanics of a newborn

Answer 35

Typically, there is a flexion contracture of up to 30 degrees present at birth. The relationship between the femur and tibia in a newborn results in a genu varum position of 15-17 degrees.

*Definitions: When we talk about the knee being in genu varum or genu valgum, we are referring to the position of the legs in the frontal plane. In genu valgum, the lower leg is positioned in an outward angle where the knees are almost touching and the feet are wide apart. To help me remember, I think about having GUM sticking my knees together. In genu varum, the knees are far apart and the ankles are closer together. In layman’s terms genu valgum is sometimes called “knock-kneed” and genu varum “bow legged.” Throughout this curriculum we will use the medical and not the layman’s terms.

Question 36

Describe knee biomechanics

Answer 36

Tibial torsion: is the transmalleolar angle relative to the knee, in the adult it should be fairly straight. Medial tibial torsion, where the tibia is turned in, usually results in a gait that is describes as an “in toeing” gait. Most of the time this resolves over time and does not cause issues later in life.

The reason the change occurs relates to weight bearing and long bone growth. This is necessary to align the
malleoli correctly for adequate foot placement during gait. If this does not occur, it can be a compensation for a
rotational malalignment proximally at the hip, femur, or distally in the foot.

The knee starts out in a genu varum position of about 15 degrees. Then by age two, it starts to become more
valgus and peaks at about 12 degrees of valgus at 3-4 years old, then resolves and decreases the valgus angle to the adult value of 5 degrees of genu valgus.

Question 37

What drives knee change from varus to valgus?

Answer 37

—Compression forces during weight bearing
—Decrease in coxa valga (increase in adduction)
—Medial distribution of weight on the foot

Question 38

Describe the biomechanics of the ankle and foot for infants

Answer 38

Infants exhibit an increase in dorsiflexion of up to 70 and decrease in plantar flexion of about 15-30º

◦In the non weight bearing position the infant ankle is usually in a resting position of 15 of dorsiflexion
◦Most of the time the metatarsal phalangeal joints are flexed and the Calcaneus is in ~10 degrees of varus, so the heel looks like it is turned inward.
◦The forefoot is also in a varus position with adduction
◦An infant’s foot does not have a visible longitudinal arch due to a fat pad that is present in the medial foot area.

Question 39

Describe the hind foot, arch, and forefoot development

Answer 39

◦The Hindfoot changes from 10° of varus to a neutral position at 3-4 years of age and continues to change to 0-2° of valgus in adults

◦Arch development:
At 1 year old you begin to see isolated foot and toe movement, and the plantar fat pad is resolving. The current biomechanical research indicates that you will not see a longitudinal arch until 2-3 years of age and it should be fully developed by 5-6 yr

◦Forefoot-The varus position of the forefoot reduces from ~6 degrees at birth to 0-2° by age 5-7 years.

Question 40

Describe biomechanics of spine for a newborn

Answer 40

◦At birth, the spine is kyphotic (spinous processes are nearly horizontal rather than having the curve noted in the adult) and the low back is in flexion.
◦The sacrum is not fully fused until the end of the first year of life.

Question 41

What are the biomechanics when an infant is placed in prone

Answer 41

◦Initially, when young children are placed in the prone position the pelvis is raised up away from the surface due to the contracted hip flexion muscles and other tight soft tissues.
◦The resulting center of gravity is more cephalic, meaning the body weight is shifted toward the head and shoulders making lifting the head or moving the arms difficult.
◦A baby in this position has to use back extensor muscles to pull against the effects of gravity strengthening those muscles. As the infant begins to develop extension through the influence of gravity, you begin to see mobility in the spine and an overall decrease in kyphosis.

Question 42

Explain the events happening when a child is in prone

Answer 42

• In prone the infant raises its head to look at her surroundings and this begins the formation of cervical lordosis.

*As the infant begins to push up, pressure is exerted back toward the pelvis, stretching the hip flexors and allowing the pelvis to tilt more anteriorly.
This marks the beginning of lumbar lordosis formation which reaches its peak around 5 years of age before decreasing back to adult
values.

• Anterior pelvic tilt is a big deal.
  Anterior pelvic ROM increases to 20-40° by age 2-3 and continues to increase to 30-40° by 5-7, then as one gains strength and control of the abdominal muscles it begins to decrease to the adult value of 15° (usually after 7 years of age).

Question 43

How does the baby’s weight need to shift to be able to lift chest up off the floor?

Answer 43

Caudal weight shift

Question 44

Describe the benefit of prone for the child

Answer 44

This baby would not be able to lift his chest up off of the floor if his weight were not shifted caudally towards his
hips and pelvis. The more the baby pushes up onto his arms, the more the weight is transferred posteriorly, the hip flexors are stretched into extension and the pelvis rests on the floor. Since the chest is unweighted, he can lift higher and higher and continue forming the lumbar lordosis. This shift in positioning and abilities is only possible because of the anterior tilt of the pelvis, the elongation of hip flexors, and the improved activation/coordination of his back extensors.

Question 45

List the age

Answer 45

1) 2 fetal months
2) 6 fetal months
3) newborn
4) 4 yr
5) 13 yr
6) adult

Question 46

Describe how the spine changes going into adulthood

Answer 46

The move toward adulthood: the spinal curves are necessary to transmit body weight from the head to feet. It takes the curves about 10 years to develop to an almost adult state, and the spine does not finish ossifying and growing until the second decade of life. In an adult, the cervical spine should have 20-40 degrees of lordosis, the thoracic spine should have 20-40 degrees of kyphosis, and the lumbar spine should have 40-60 degrees of lordosis.

Question 47

Describe early upper extremity developmental changes

Answer 47

Upper Extremity: More prone!!!
* As the baby lies prone, active abduction of the scapular muscles decreases the scapular protraction and assists in rotating the scapula upward, helping to move the the glenoid fossa into a lateral and slightly upward position. This position enhances humeral flexion and adds in stability of shoulder girdle.
* The weight bearing on hands stretches finger and wrist flexors as well as, provides sensory input into the palm of the hand. Prone on elbows also helps develop serratus anterior muscle strength and overall arm strength necessary for UE protective extension which will be needed in sitting and standing.

Question 48

Describe the upper extremity developmental changes 6 mo and beyond

Answer 48

◦As the baby gets closer to the 6 months old, you begin to see more
lifting of the chest off of the surface and weight shifting while in the prone position. This weight shifting elongates the forearm and wrist getting them ready for further activities as well as allowing for one hand to be unweighted, so they can begin to reach and grab objects.
◦Finally the 6-7 month old reaches with full supination, a prerequisite for self care. It takes a lot of strength and control to reach the arm up against gravity and then hold while you supinate to grasp an object. It takes around 5-6 months of work to achieve this activity.

Question 49

Describe locomotion, ambulation, gait, cadence

Answer 49

• Locomotion-Moving from one place to another, it does not matter how
• Ambulation-to walk from place to place
• Gait-the detailed description of walking
• Cadence-the number of steps taken in a given amount of time, typically measured in steps/ minute

Question 50

Describe phases of gait

Answer 50

• Initial contact-the moment the foot contacts the ground
• Loading response-weight is rapidly transferred onto the outstretched limb
• Midstance-the body progresses over a single, stable limb
• Terminal Stance-progression over the stance limb continues, the body moves ahead of the limb and weight is transferred to forefoot.
• Preswing-rapid unloading of the limb as weight is transferred to the contralateral limb
• Initial swing-the thigh begins to advance as the foot comes up off the floor
• Midswing-the thigh continues to advance as the knee begins to extend; the foot clears the ground
• Terminal swing-the knee extends; the limb prepares to contact the ground for initial contact.

Question 51

Describe learning how to stand

Answer 51

Standing-The first thing an infant must do in order to walk is gain postural control and strengthen antigravity muscles. The new stander has to contract almost every muscle in their body to stay upright. Notice the wide base of support: the hips are in flexion, abduction and external rotation, knees are flexed. Arms are in what’s called a high guard position and the trunk is slightly tilted backwards.

Question 52

Describe gait (early walkers)

Answer 52

Early Walking: Most typically developing children walk between 11-18 months. o In standing, the hips are still in abduction, external rotation, and flexion.
*The knee is in a genu varum position, helping to maintain that wide base of support. Once they feel confident enough in their ability to weight shift, an infant’s first steps have a short in stride length and initial contact is with the full foot.
*Once more steps in sequence can be achieved, a baby’s cadence increases. Other hallmarks of the early walker are a prolonged stance phase and shorter single limb support phase.
*New walkers display a high guard position or mid guard positions until about 18 months of age.

Question 53

What are the limiting factors that prevent infant/toddler from walking as soon as they stand?

Answer 53

*Extensor strength is a critical component necessary for gait. The young infant has insufficient extensor strength and poor dynamic balance/ standing motor control. This insufficient control of the center of mass over the base of support (dynamic balance) is due to poor/ immature neuromuscular control/ coordination. As the infant matures, they gain the postural control and strength necessary for the lateral weight shifts required for gait. Gait is sometimes referred to as a controlled series of falls, and early “walkers” lack the control to recover from the initial “fall” or two.

Question 54

Describe gait (18-24 mo)

Answer 54

Practice! Usually by ~18 months, the varus of the knee has resolved and the lower limb appears straight.

• This is dependent on how long the toddler has been walking/ weight bearing, as the pull of muscles and the stress on the bones during standing and walking are what provide the forces to straighten the leg.
• At this point, walking experience is very important in the continuation of gait development and achieving the mature gait pattern. Like anything else, walking improvement requires practice!
• Heel strike instead of flat-footed initial contact emerges around 18 months (if the child walks at 12 months)and is consistent by 24 months.
• It usually takes 6 months for heel strike to emerge, so the later a child walks the later heel strike will emerge.
  *Cadence has decreased and overall walking efficiency has improved.
  *EMG studies show a decrease in global co-contraction, implying an increase in motor control and stability.
  Functionally the toddler’s dynamic balance has improved.
• 92% of all 2-year-olds demonstrate a reciprocal arm swing and by 4 all children should exhibit an arm swing.

Question 55

Describe gait (2-3.5 yr)

Answer 55

More Practice! From 2-3 years, toddlers are frequently walking and with practice, becoming more efficient with their gait.

• From 3-3.5 years, children again are continuing to refine their balance reactions.
• Joint angles in the lower extremities are associated with adult levels except that the LE is now in a genu valgum position, which lowers the COM. (look at that chart in the Campbell text again)
• Some researchers say that the gait pattern is mature by 3 years of age, while others argue it is between 5 and 7 years old. Clinically, I tend to agree with the latter. What biomechanical reason would I have for this thought?
  *Remember Karen Adolph’s work, the frequency of falling, and the distances needed to transition from the “early walking” phase, through this phase, and to the next phase on this next slide.
  *“A child’s ‘job’ is to play!”

Question 56

Describe gait (6-7 yr)

Answer 56

Gait is fully mature and adult like by ~ 7 years old.

*The necessary biomechanical changes of the LE have resulted in the tibiofemoral angle close to neutral and the anteversion of the femur is near adult like.
The child’s center of mass is still higher in the trunk than the adult which puts them at a greater risk for falls than the adult.
*As the child continues to grow, the COM will continue to move in the caudal direction to towards the S-2 level of the adult.

Question 57

What are the traits of the initial stage of walking?

Answer 57

1. Difficulty maintaining upright posture
2. Unpredictable loss of balance
3. Rigid, halting leg action
4. Short steps
5. Flat-footed contact
6. Toes turn outward
7. Wide base of support
8. Flexed knee at contact followed by quick leg extension

Question 58

What are the traits of the elementary stage of walking?

Answer 58

1. Gradual smoothing of pattern
2. Step length increased
3. Heel-toe contact
4. Arms down to sides with limited swing
5. Base of support within the lateral dimensions of trunk
6. Out-toeing reduced or eliminated
7. Increased pelvic tilt
8. Apparent vertical lift

Question 59

What are the traits of the mature stage of walking?

Answer 59

1. Reflexive arm swing
2. Narrow base of support
3. Relaxed, elongated gait
4. Minimal vertical lift
5. Definite heel-toe contact

Question 60

What are some common problems when developing the ability to walk?

Answer 60

A. Inhibited or exaggerated arm swing
B. Arms crossing midline of body
C. Improper foot placement
D. Exaggerated forward trunk lean
E. Arms flopping at sides or held out for balance
F. Twisting of trunk
G. Poor rhythmic action
H. Landing flat-footed
1. Flipping foot or lower leg in or out