Spontaneous Motility Disorders and Postural Control in Infants (0-6

Medical Rehabilitation (Med Rehabil) 2015, 19 (1), 25-33 eISSN 1896–3250 ISSN 1427–9622 © AWF Kraków

Spontaneous motility disorders and postural control in infants (0-6 months of life) with a history of perinatal disorders Zaburzenia motoryki spontanicznej oraz kontroli posturalnej u niemowląt (0-6 miesiąc życia) z obciążonym wywiadem okołoporodowym

Magdalena Czajkowska

FinMed, Rehabilitation Center, Szczecin, Poland

Key words early physiotherapy intervention, neonatal reflexes, Vojta method, standard pattern, segmental extension, locomotion

Abstract Newborn infants with a history of perinatal neurological conditions require special monitoring. Their psychomotor development is determined by the potential damage to the structure of their immature nervous system, perinatal hypoxia or disharmony in motor development. However, muscle tension disorders and minor postural control issues, in the light of the high plasticity of the brain, can be independently adjusted. What is more, in most cases infants need help from the moment of birth, and the first signs of irregularities occur within the first weeks of life. The first signs of disturbances in motor development are frequently found by an infant’s parents or guardians. They have the opportunity to observe the infant in natural settings, such as during care, play or feeding. Care- ful clinical examination performed by a pediatric neurologist takes into account an assessment of the child’s eye contact, spontaneous motor activity and support and erectile mechanisms, and also evaluates the child’s neonatal reflexes and postural reactions (in the case of a diagnosis by Vaclav Vojta). Early physiotherapy intervention shall take action when the first signs of delayed motor development appear in the infant. Knowing the exact course of the child’s normal psychomotor development, a physical therapist can evaluate the qualitative and quantitative values of individual movement patterns. Postural control disorders inhibit the progress of spontaneous motor activity and the formation of support and erectile mechanisms. As a result of these irregularities, the learning of locomotion becomes limited or completely inhibited, and thus the segmental spine extension which is essential in obtaining rotation is stopped. Children with cerebral palsy never reach the quality of motor development of an infant over three months of age. Their impaired postural control, resulting from damage to the brain, inhibits the possibility of the extension of individual segments of the spine, especially their active setting them in the midline. Therefore, it is important that children undergo immediate therapy when the first symptoms of disorders of central nervous coordination appear.

Słowa kluczowe wczesna interwencja fizjoterapeutyczna, odruchy noworodkowe, metoda Vojty, wzorzec globalny, wyprost segmentalny, lokomocja

Streszczenie Noworodki urodzone z obciążonym wywiadem okołoporodowym wymagają szczególnego monitoringu neurologicznego. Ich rozwój psychoruchowy determinowany jest potencjalnym uszkodzeniem struktur niedojrzałego układu nerwowego, niedotlenieniem okołopo- rodowym lub dysharmonią w rozwoju motorycznym. Zaburzenia kontroli napięcia mięśniowego czy kontroli posturalnej niewielkie- go stopnia, w świetle możliwości plastyczności mózgu, mogą zostać samodzielnie wyregulowane. Najczęściej jednak niemowlę potrze- buje pomocy i pierwsze symptomy nieprawidłowości prezentuje już w pierwszych tygodniach życia. Pierwsze objawy zaburzeń w rozwoju motorycznym najczęściej zauważają rodzice/opiekunowie. Mają oni możliwość obserwacji niemowlęcia w warunkach natural- nych, domowych, podczas pielęgnacji, zabawy czy karmienia. Dokładne badanie kliniczne, wykonane przez neurologa dziecięcego, bierze zaś pod uwagę ocenę kontaktu wzrokowego dziecka, motorykę spontaniczną, mechanizmy podporowo-wyprostne, realizację odruchów noworodkowych oraz ocenę reakcji posturalnych (w przypadku diagnostyki wg Vaclava Vojty). Wczesną interwencję fiz- joterapeutyczną podejmuje się najczęściej, gdy pojawiają się pierwsze opóźnienia w rozwoju ruchowym niemowlęcia. Znając dokład- ny przebieg prawidłowego rozwoju psychomotorycznego dziecka, fizjoterapeuta ocenia jakościowe i ilościowe wartości poszczegól- nych wzorców ruchowych. Zaburzenia kontroli posturalnej hamują postępy motoryki spontanicznej oraz kształtowanie się mecha- nizmów podporowo-wyprostnych. W konsekwencji tych nieprawidłowości nauka lokomocji staje się ograniczona lub całkowicie za-

Article received: 08.12.2014; accepted: 11.04.2015

Please cited: Czajkowska M. Spontaneous motility disorders and postural control in infants (0-6 months of life) with a history of perinatal disorders. Med Rehabil 2015; 19(1): 25-33

Internet version (original): www.rehmed.pl

25 Medical Rehabilitation (Med Rehabil) 2015, 19 (1), 25-33 eISSN 1896–3250 ISSN 1427–9622 © AWF Kraków

hamowana, a co za tym idzie, wyprost segmentalny kręgosłupa, niezbędny w uzyskaniu ruchów rotacyjnych, zostaje powstrzymany. Dzieci z mózgowym porażeniem dziecięcym nigdy nie osiągają jakościowo rozwoju motorycznego niemowlęcia powyżej 3. miesiąca życia. Ich zaburzona kontrola posturalna, wynikająca z uszkodzenia struktur mózgu, hamuje możliwości wyprostu poszczególnych segmentów kręgosłupa, czyli aktywnego ustawienia ich w linii środkowej. Dlatego tak ważne jest podjęcie natychmiastowej terapii w przypadku pierwszych symptomów zaburzenia ośrodkowej koordynacji nerwowej.

Newborn infants with a history of per- the extension of individual segments –– low Apgar score – below 5 points inatal neurological conditions require of the spine, especially their active set- in the 5th minute of life, special monitoring. Their psychomo- ting them in the midline. Therefore, it –– infant respiratory distress syn- tor development is determined by the is important that children undergo im- drome (IRDS) and a prolonged potential damage to the structure of mediate therapy when the first symp- mechanical ventilation, their immature nervous system, per- toms of central coordination disorders –– meconium aspiration syndrome, inatal hypoxia or disharmony in mo- (CCDs) appear2-7; R62.0 – a delayed –– hypoxic-ischemic encephalopathy tor development. However, muscle milestone in childhood, according to and an abnormal EEG reading, tension disorders and minor postural the International Classification of Dis- –– intracranial bleeding, especially control issues, in the light of the high eases (ICD-10). Grades III and IV, plasticity of the brain, can be inde- –– periventricular leukomalacia, pendently adjusted. What is more, in Psychomotor assessment –– congenital heart disorder, most cases infants need help from the of an infant –– congenital developmental condi- moment of birth, and the first signs tion, of irregularities occur within the first The assessment of psychological devel- –– neonatal infection, weeks of life. The first signs of distur- opment during the first three months –– intrauterine infection – especially bances in motor development are fre- of extrauterine life forms the basis of from the TORCH group, quently found by an infant’s parents neurodevelopmental diagnostics. Dur- –– hypoglycaemia, or guardians. They have the oppor- ing a kinesiological assessment of the –– hyperbilirubinemia, tunity to observe the infant in natu- postural model, a physiotherapist is –– multiple pregnancies and inhibited ral settings, such as during care, play able to determine whether the first intrauterine growth, or feeding. Careful clinical examina- neurological disruptions, due to a his- –– retinopathy of prematurity. tion performed by a pediatric neurol- tory of perinatal disorders, have oc- A history of the perinatal disorder ogist takes into account an assessment curred. The assessment of social con- will form the basis of the detailed of the child’s eye contact, spontaneous tact, antigravitational mechanisms7, neurodevelopmental controls and di- motor activity and support and erec- postural control, and the development agnostics of an infant. a paediatri- tile mechanisms, and also evaluates the of the support and erectile mechanisms cian should inform the infant’s par- child’s neonatal reflexes and postural can help to determine the direction of ents/caretakers that, due to the poten- reactions (in the case of a diagnosis by maturation of the central nervous sys- tially harmful factors their child was Vaclav Vojta)1. Early physiotherapy in- tem (i.e. towards pathology or nor- exposed to during the prenatal peri- tervention shall take action when the malisation) following a traumatic per- od, they should report any disturbing first signs of delayed motor develop- inatal period. Valuable insights can be symptoms. ment appear in the infant. Knowing gained from the infant’s caretakers (the the exact course of the child’s normal best observers of a small child). Also, Paediatric physiotherapy psychomotor development, a physical a referral from the attending physi- in practice therapist can evaluate the qualitative cian leading to an early intervention, and quantitative values of individual and a physiotherapist’s knowledge and In neonatal physiotherapy practice, movement patterns. Postural control experience may stop or minimise the the greatest anxiety is related to the disorders inhibit the progress of spon- danger of the motor disability as early risk of perinatal hypoxia and the po- taneous motor activity and the forma- as during the first months of life. tential development of cerebral pal- tion of support and erectile mecha- sy (CP). The main diagnostic process nisms. As a result of these irregular- History of perinatal disorders during the assessment of the motili- ities, the learning of locomotion be- as the basis for a detailed ty of the first six months focuses on comes limited or completely inhibited, observation of the infant assessing the infant’s antigravitational and thus the segmental spine extension mechanism7, postural control, muscu- which is essential in obtaining rotation Factors that should be taken into ac- lar tension regulation and eye-motor is stopped. Children with cerebral pal- count comprise8-12: control, as well as on suppressing the sy never reach the quality of motor –– stage of the pregnancy at birth infant’s primitive reflexes. development of an infant over three (23th-37th week of pregnancy – During the first day of an infant’s months of age. Their impaired pos- prematurity), life, the immature central nervous sys- tural control, resulting from damage –– low birth weight, especially below tem (CNS), i.e. the spinal cord and the to the brain, inhibits the possibility of 1500 g, brain stem, functions at a lower level.

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Primitive reflexes dominate in the in- sion of the orbicularis oris muscle10. Plantar reflex fant motility. Each subsequent week The literature also mentions a patho- The plantar reflex is triggered by then involves an on-going dynamic logical neuromuscular regulation of touching (stroking) the anterior part development of the subcortical and the tongue, where the reduced mus- of the sole of the foot, at the base of 13 cortical centres of the encephalon . cle tension in the tongue causes it to the phalanges. This stimulation engen- become wedge-shaped, and this pre- ders a tonic plantar flexion of all toes. Infant reflexes – their vents the baby from maintaining the The reflex disappears in the fourth tri- assessment and their nipple on the palate. In turn, the in- mester as the support function of the suppression time creased tension causes unforced non- foot develops. If during the second rhythmic movements and disrupts and third quarter of life, the reflex Sucking reflex the synchronisation between col- is found to be too weak or non-ex- The sucking reflex is the most primi- lecting milk and transporting it to 14 istent, this can indicate a serious risk tive of infant reflexes. It ensures sur- the oesophagus . a muscular imbal- of spasticity, whereas an excessive- vival through maintaining and devel- ance following prolonged mechan- ly strong reflex can indicate a risk of 14 ical ventilation, a forced position of oping nutritional functions . a healthy dyskinesia20. infant shows the strongest sucking re- the head and shoulder girdle during intubation, the head arching back- flex about 2-3 hours after birth. When Primitive extension reflex unstimulated, this reflex can disappear wards, and generalised tonic spasms The child is held by its trunk, and its in the 5th day, and the sucking reflex can also prevent or hamper the cor- head is maintained in a vertical posi- can also be suppressed by, e.g., medi- rect sucking reflex. a thorough clini- tion. Next, the child is lowered until cal procedures14. a physiotherapist can cal interview following an account of its feet touch the ground. The child trigger the reflex by placing his or her intracerebral bleeding, bleeding into responds to this stimulation by sud- finger onto the infant’s tongue (me- the subventricular zone, and respira- denly extending its legs and trunk. dial dorsum) or by touching the in- tory distress syndrome should con- This reflex is at its strongest up to fant’s (upper and lower) lip line at stitute a crucial factor that will mo- the fourth week of life, and its oc- the symmetry axis of the face. In re- tivate the physiotherapist to instigate currence after the third month of life sponse, the child will begin to display further observations of the infant. The constitutes a developmental patholo- sucking movements that involve a full sucking reflex shows the highest in- gy. An excessive reflex, i.e., excessive adhesion of the orbicularis oris mus- tensity up to the third month of ex- contraction within the antigravitation- cle15-18. The sucking will last as long trauterine life; whereas in the second al system, will lead to opisthotonus, as the stimulation continues; however, trimester, the reflex sucking will oc- and indicates a dominance of the ex- every child has an individual rhythm cur alongside voluntary sucking. The of responses to the stimulation. On av- most important consideration, from tensor tension over the flexor tension the viewpoint of physiotherapeutic (which in turn indicates an influence erage, the rhythm should range from 13 42 to 46-48 sucking motions per min- diagnostics, is the fact that after the of the corticospinal system) . 14 6-7th month of life reflex sucking in ute . Other literature on the subject 20 also mentions a frequency of 42-84 an infant is viewed as pathological . Stepping reflex sucking motions per minute. Thus, The child is held in the same manner the correctness of the sucking reflex Palmar grasp reflex as when the support reflex is triggered. can be assessed immediately within the The palmar grasp reflex is triggered When its feet touch the ground, the first days of the infant’s life. by touching (stroking) the palm of the therapist bends the child’s truck slight- There are many causes of disorders hand. In Phase I, the infant’s flexors ly forwards, putting more weight on in this reflex, and significant informa- are stimulated, and the child will grasp one of the feet. In response, the child tion can be obtained from a perinatal the stroking finger. Phase II involves alternates between flexing and extend- interview. The most frequent causes a chain reaction of the flexors of the ing its legs and bends its trunk forward. of abnormal sucking are prematuri- forearm, the arm, and the shoulder This reflex is the most intense up to the ty (as the reflex may be underdevel- that can even allow the child to be fourth week of life, and its occurrence oped in infants born prior to their lifted. This reflex shows the highest after the third month of life indicates 29th week of life)15,19. Difficulties in intensity at about the 5-6th month of pathology; whereas a lack of the reflex sucking may also stem from a short- life, and then disappears with the de- up to the fourth week of life indicates ened frenulum of the tongue. Other velopment of the grasping and sup- a damaged CNS13. reasons include damage or abnormal- port functions of the hand. If during ities in the nervous structures respon- the first quarter of life, the reflex is Moro reflex sible for other orofacial reflexes, such found to be too weak or non-exist- as: excessive tongue thrusting, vomit- ent (i.e. the child does not react at all The Moro reflex is triggered by a rap- ing, biting reflexes, the lack of a jaw to stimulation), this indicates a risk idly appearing stimulus, e.g. a loud jerk reflex (where the child is unable of dyskinesia. On the other hand, an noise or a sudden movement of the to purse its lips and keep its tongue excessively strong reflex can indicate child’s body, as in when changing the on the palate)14, and a reduced ten- a risk of spasticity20. diaper, dressing, or lifting from a sur-

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face. The infant’s arms and legs jerk The child’s functioning during the and older children, both healthy chil- outwards symmetrically (Phase I), and first weeks of life is based on reflexes dren and those with a damaged CNS, then are abducted towards the chest controlled by the brain stem that se- Vojta was able to systematise the stag- through a holding motion (Phase II). cure its survival in the new, extrauter- es of a child’s motor development and Children born prematurely will dis- ine environment. Together with sight to create what is referred to as the ide- play only the first phase before their and motor development, the higher al model of a child’s motor develop- 34th week of foetal life, and both cerebral centres begin to take shape ment. He determined the age at which phases afterwards11. In healthy-born and to dominate. This motor develop- individual ‘milestones’ should appear, children, the reaction will gradually ment is driven by the infant’s motiva- and also specified their qualitative and fade between the second and fourth tion and interest in exploring its sur- quantitative values. months of life2, with its peak inten- roundings. Therefore, detailed obser- sity occurring in the first month. vations of the child’s behaviour dur- Fencing pattern a lack of this reflex indicates a dam- ing feeding, dressing, grooming, and aged CNS or excessive muscle hypo- waking time will provide significant A 6-week-old infant with a correct tonia; whereas a persistent reflex can cues and information about whether psychomotor development will dis- indicate a high probability of severe the development is correct or patho- play the fencing model, named af- cerebral palsy. a unilateral Moro re- logical. Spontaneous motility can be ter the characteristic pose it assumes flex may also indicate peripheral dam- evaluated as soon as the first weeks while fixating its sight on its hand. age to the nerve roots (occurring e.g. of life. a physiotherapeutic assessment Its limbs will assume a position similar alongside damage to the brachial plex- first and foremost takes into account to that when the ATNR is triggered, us) or a risk of hemiplegia. eye contact and fixation. a distance of with the difference that the movement about 20-25 cm will make it easier for of the head is not directed by another Asymmetrical tonic neck reflex the child to focus its sight on a giv- person. Driven by curiosity, the child (ATNR) en object, as long as its head is sta- will turn its head sideways on its own, 4 This reflex is triggered by turning the bilised and supported . The fixation and extends its arm in the same direc- head sideways while the infant is ly- effectiveness should amount to about tion. The arm will be slightly rotat- ing on its back. In response, the in- 50% within one minute in the fourth ed outwards in the shoulder joint, the fant will extend its arm and leg on the week of life. According to the diag- hand loosely clenched into a fist, and same side towards which its head was nostic method by Vaclav Vojta, a six- the wrist positioned radially. The leg turned, and will flex its limbs on the week-old child should show a fixation on the same side of the body is free- other side (due to a tonic increase in effectiveness of 75%, and a 3-month- ly extended, while in the other side the tension of the extensors of arms old child should be able to fixate on the arm is slightly flexed, the hand is 6, and legs on the side the infant’s head a given object or face at a distance of slightly clenched into a fist and the is facing). This reflex shows its high- about 20-25 cm at 100%. leg slightly flexed and positioned in est intensity between the second and the external rotation in the hip joint. fourth month of life. Its occurrence af- Ideomotor development of a child This constitutes an important global ter the sixth month of life is patho- pattern, as this is the first time when logical. a persistent ATNR disrupts After many years of observations of the child’s external rotators of the the psychomotor development in the the development of babies, infants, large peripheral joints are activat- midline and will hamper palmar grasping development, manipulative func- Table 1 tions of the arms, and the support and Infant reflex reactions (based on the author’s own elaboration) erectile mechanisms3. An infant with an extensive and persistent ATNR will Reflex Norm and fade time Pathology be unable to support itself on its fore- Sucking reflex up to the 3rd month after the 6th month arms when lying face down in order to Palmar grasp reflex up to the 5-6th month after the 6th month become prepared for crawling. weak or non-existent: risk of dyskinesia Symmetrical tonic neck reflex excessive: risk of spasticity (STNR) Plantar grasp reflex up to the 4th trimester weak or non-existent: risk of with verticalisation spasticity The STNR is triggered when the child’s excessive: risk of dyskinesia head is bent forwards (Phase I). In re- Primitive extension up to the 4th week after the 3rd month sponse, the infant will flex its arms and Stepping reflex up to the 4th week after the 3rd month extend its legs. During Phase II, the in- Moro reflex 2-4th month after the 6th month fant’s head is bent backwards, and in ATNR 2-4th month after the 6th month response the infant will extend its arms and flex its legs. STNR persisting after STNR 3-6th month after the 6th month the sixth month of life is pathological. Abbreviations: ATNR- Asymmetrical tonic neck reflex; STNR- Symmetrical tonic neck reflex

28 Medical Rehabilitation (Med Rehabil) 2015, 19 (1), 25-33 eISSN 1896–3250 ISSN 1427–9622 © AWF Kraków ed21. Knowing this, a physiotherapist selective movements of the head, the Children with postural control disor- is able to notice the first pathologi- child also has to have the correct ‘pos- ders are unable to perform this pat- cal symptoms in the child’s body postural reaction abilities’4. The pattern is tern. The hand-hand coordination re- ture control. For the legs, these sys- a very important indicator in assessing quires active external rotators of the tems involve a significant internal ro- whether a 12-week-old child is devel- arms. Also significant from the view- tation and abduction dependent on oping correctly, and the quality of this point of a physiological assessment an increased anteversion of the pel- ability can provide a physiotherapist is a child’s inability to concurrently vis. The infant will represent incor- with cues about the child’s postural lift both legs bent at the knee and hip rect motor patterns, referred to as control, the positioning of the shoul- joints without losing stability while in substitution patterns, as early as the der girdle and the pelvis relative to the the supine position. first weeks of active eye orientation21. spine, and the segmental extension of individual sections of the spine. When Spherical grip pattern Forearm support pattern the antigravitational mechanisms develop, the pectoralis major, coracobra- The spherical grip pattern appears in In its sixth week of life, the infant will chialis, and subscapularis muscles will four-month-old infants as part of their achieve the forearm support pattern in begin to be active due to the point of ideomotor development. a therapist a prone position. The first support and support created in the area of the el- can assess this ability qualitatively by erectile mechanisms take shape when bow joint when the infant supports it- moving a toy from the side towards the child attempts to lift is head and self21. a full segmental extension of the the child’s right hand when it is lying to fixate its sight on a toy or another spine and an intermediate position of on its back. The abilities assessed are: object. The infant, by lifting its body, the pelvis are dependent on the ac- the quality of the grip in each hand, functionally supports itself on the tivity of the autochthonous muscles the openness of the hand, the adduc- central parts of its forearms, near the of the spine and the ventral and dor- tion of the metacarpus, the position of wrist joints, with the elbows remain- sal muscle layers in the trunk4. This the wrist, and the muscular balance of ing in the caudal position. The wrist mechanism operates in synergy with the external and internal rotation of gradually leaves the ulnar induction, the created points of support, and all the humerus and the forearm bones. and the adduction of the metacarpus of these processes are inextricably tied 4,21 begins . Also, the anteversion of the to a correctly functioning CNS. Chil- Asymmetrical support pelvis decreases, causing the weight dren with CP will never fully achieve on the elbow pattern and the centre of gravity of the body this ability, which requires the afore- to shift caudally. The epigastrium and mentioned mechanisms. Furthermore, Another ability assessed by a physio- both forearms create a triangle of sup- if the child is unable to achieve the therapist is the asymmetrical support port, and this constitutes the activity segmental extension of the spine due on the elbow pattern. On average, of the support and erectile mecha- to a disorder, a correct triangle of sup- a child will achieve this pattern after nisms and the child’s first attempts to port is not created, and then selective 4-5 months of life. While prone, the combat gravity6. movements of the head are impossi- child reaches for a toy lying in front ble. At this time, the ball joints con- of it. Three points of support are cre- Symmetrical support tinue to show the dominance of inter- ated: on the elbow, on the upper part on the elbows pattern nal rotation, and thus function only as of the thigh on the same side of the hinge joints21. body, and in the area of the knee in The symmetrical support on the el- the opposite (flexed) leg. As about bows develops to reach perfection in Stable supine position pattern two-fifths of the body mass is locat- the 12th week of life. The pattern en- and hand-hand coordination ed outside the plane of support, the ables the infant to perform an isolated pattern child needs to have the correct pos- sideways movement of the head (about tural control in order to reach an in- 60°) and an isolated movement of the A 12-week-old infant should display teresting object, and for the first time eyes (about 30°). Correct postural con- a hand-hand coordination pattern the spine segments at the thoracolum- trol will allow the infant to observe its and the ability (pattern) to remain bar junction can be rotated4,21. surroundings in this position without stable while supine. Isolated side- the risk of falling onto its side, bend- ways movements of the head should Support on the hands pattern ing, losing the support of the elbow, or not disrupt the stability of the su- relaxing the hand. The points of sup- pine position, and the child should A subsequent milestone in the child’s port in this pattern are creased on the have no difficulty in using its sight motor development is support on epicondyles of the humerus and the to join its hands together in the mid- the hands, achieved at the age of six area of the pubic symphisis3. The cen- line above its chest. a segmental ex- months. While prone, the infant can tre of mass continues to shift and the tension of the spine positions the pel- support itself on open hands (symmet- head, which constitutes one-third of vis intermedially; thus, the child’s legs rical support on the hands pattern), the body mass, is located outside the (slightly adducted and rotated exter- with the chest lifted high above the plane of support. In order to perform nally) begin to work against gravity. ground.

Rolling over pattern –– chin shaking during spontaneous –– limbs shaking and difficulty in movements in a relaxed child from flexing, as well as legs adducted Simultaneously, the child learns to roll the second month of life, during grooming and dressing, over from its back to its belly. This is –– convulsions, apnoea, pulsating –– legs aligned in a ‘frog’ position called the rolling over pattern and re- crown. with a characteristic adduction, quires several abilities, e.g. shifting be- flexion, and external rotation in yond the midline, use of the muscle Supine position the hip joints, with knees signif- chains, full postural control, and pha- icantly adducted on the ground sic movement coordination. a child The most frequently observed disor- and feet supported on their exter- with a central coordination disorder ders are3,20,22: nal edges. (CCD) cannot perform this pattern –– pushing the head into the ground correctly. while looking up and back, or a per- Prone position Knowing the order of the individu- manent backwards arching of the al global patterns in the development head (only in prematurely born chil- The most frequently observed disor- of a small child and their quantita- dren up to the 3rd month of life), ders are3,5,20,22: tive and qualitative values will allow –– an open mouth while the head is –– no attempts to lift the head above a physical therapist to assess any ab- arched backwards, the ground, normalities resulting from a history –– asymmetrical, stereotypical posi- –– strong backwards arching of the of perinatal disorders. Additional as- tions of the head head with tonic spasms in the legs sessments of the infant reflexes and –– weak stabilisation of the head and a difficulty with support on postural reactivity provides comple- when lifting the child by its hands the forearms, mentary information during a medi- after the sixth week of life, or –– difficulty with maintaining sup- cal interview with the physical thera- a lack thereof, port – the elbows move backwards pist and/or physician. –– a bridge position and arching of or the infant falls onto its side, the entire body, –– considerable difficulty with mov- –– spontaneous or provoked opisto- ing the forearms forwards (af- Symptoms of abnormal tonus (hyperextension and spastic- ter the sixth week of life), where development ity of the entire body), the child aligns one or both limbs Usually, before a child is brought to –– asymmetrical alignment of the along its trunk, a physical therapist, its parents, a pae- shoulders (protraction or retrac- –– shoulders aligned asymmetrically diatrician, or a neurologist has noticed tion of the shoulders), (in protraction or retraction) dur- disturbing symptoms. The characteris- –– stereotypical alignment of the ing the support on the forearms, tic symptoms indicative of an abnormal arms and legs during abductions –– difficulty with maintaining the psychomotor development are gener- and internal rotations, and clench- prone position, with falling to the ally noticed in relation to the child’s ing the hands into fists (so that the side or onto the back, social contact and spontaneous move- hands are open only during the –– legs aligned in the ‘frog’ position, ments. Moro reflex), –– homologous activity of the legs –– abducting the thumb towards the during flexion or extension, end of the first quarter and the –– feet constantly and abnormally Social contact subsequent quarters, aligned in a dorsiflexion or plan- The most frequently observed disor- –– tonic spasms and internal rotation tar flexion alongside genu valgum ders are3,20,22: of the legs, or genu varum, –– hypersensitivity, restlessness, low –– feet aligned in a ‘ballet’ position –– toes tightly clenched, need for sleep, and an abducted metatarsus, –– chaotic and violent kicking. –– permanent strabismus or the ‘setting sun’ sign, Table 2 –– lack of initiative to establish eye Global patterns (based on the author’s own elaboration) contact with the surroundings af- Time of appearance during motor Global pattern ter the first month of life, development –– very weak ability to follow an ob- Fencing pattern 6th week ject with the eyes and head, or Support on the forearms pattern 6th week a lack thereof, from the second Symmetrical support on the elbows pattern 3rd month month of life, Stable supine position pattern 3rd month –– difficulties in, or inability to, Hand-hand coordination pattern 3rd month maintain sight in the midline after Spherical grip pattern 4th month the third month of life, Asymmetrical support on the elbow pattern 4th-5th month –– weak reaction to light, or a lack thereof, after the third month of Support on the hands pattern 6th month life, Rolling over pattern 6th month

The presence of the aforementioned the spine. Consequently, the head is that the segmental extension must symptoms constitutes reliable infor- turned sideways through the crani- occur along the entire length of the mation about a disruption in a child’s ocervical junction, at the level of spine. Autochthonic muscles “guide motor development. The physician the atlas and the axis5. With the pro- the spine in the sagittal, coronal, and should assess the severity of these gression of sight and motor devel- transverse planes so that its individ- disruptions using Vojta’s diagnosis opment in a 6-week-old child, the ual segments actively align (extend) method (including an assessment of hyperlordosis gradually diminishes, along the midline in relation to one the spontaneous motility, infant re- and the muscle layers located on the another”5. Consequently, the pelvis flexes, and the positional responses dorsal (longissimus capitis, longissi- aligns in an intermediate position, in space). CCD constitutes a tempo- mus cervicis, interspinales, semispi- and the muscles in the area of the rary and symptomatic diagnosis of in- nalis cerivcis, and spinalis cervicis) hip joints are able to achieve a syn- fants up to the first year of life, on and the ventral (longus capitis and ergy between muscle tension and average, and the disruption may be longus colli) sides of the neck walls readiness for locomotion. In turn, caused by a disharmonic maturation become active. Correct coordination the extension in the thoracic section of a non-damaged brain, anatomical and synergy between these layers of the spine guarantees a synergy of and structural brain damage, or by se- will provide the child with the abili- the muscle work between the area verely disrupted metabolic processes8. ty to extend the individual segments of the shoulder blades and shoulder CCD is also a transitional state dur- of the neck spine. The spine autoch- joints, providing support functions ing the risk period for cerebral pal- thons, i.e. short muscles of the deep in the arms and manipulative func- sy, which is another reason why it is layer, “connect individual vertebrae tions in the hands. important that an infant showing this either directly one after another or A disrupted or delayed segmen- symptom undergoes rehabilitation as every second or third vertebra”5, tal extension of the spine, occurring quickly as possible. and this allows for individual verte- alongside a disharmonic postural con- According to the Vojta method, brae to extend in relation to one an- trol, will determine spontaneous mo- the symptoms of disharmony in the other and for the rotational planes tility. Detailed knowledge about the spontaneous motility predominantly of the intervertebral joins to move development of a small child can al- include: freely. a persistent reclination of the low early support treatment to begin –– incorrect postural control (auto- head and the lack of a segmental ex- within the first weeks of life. matic control over the body and tension of the spine after the third The most frequent qualitative dis- the posture independent of the month of life occurs in all children ruptions to spontaneous motility in child’s will)3, at risk of cerebral palsy and any mo- infants during the first six months of –– lack of support and erectile mech- tor disorders6. Vojta also indicates life are presented in Table 3. anisms (or difficulty with executing them), Table 3 –– disrupted, phasic forwards movement of the limbs (with incor- Qualitative abnormalities of global patterns, according to the Vojta method (based on the author’s own elaboration) rect regulation of the muscle tension)23. Global pattern Disruptions to the spontaneous motility These three patterns provide the Symmetrical support on the el- • reclined head, inability to rotate the head bows in the cervical vertebrae, child with its means of locomotion, • rotation occurs along the entire cervicothoracic from rolling over, through to crawl- section of the spine, ing and walking. Problems with ex- • no segmental extension of the cervical and thoracic sections of the spine, ecuting these patterns are already • craniolateral alignment of the shoulder blades, noticeable in a 3-month-old infant protracted shoulders, and internal rotation of the humeri, through its reclination of the head • difficulty with moving the arms forwards and its lack of segmental extension in the prone position and with executing support of the spine. a reclined head will and erectile mechanisms, prevent or hamper the correct sup- Rolling over from the back onto • incomplete segmental extension of the port of the elbows in the prone posi- the tummy thoracolumbar junction in the spine, • incomplete alignment of the pelvis in the tion, and a lack of segmental exten- intermediate position leading to the inability sion of the spine will lead to an in- to rotate the lower parts of the trunk, • unbalanced functioning of the muscle chains ability to perform rotational move- in the anterior wall of the trunk. ments, isolated movements of the due to a prolonged mechanical ventilation during head relative to the trunk, and iso- the first days (weeks) of life, the neck and head may show a persistent backwards arch, lated movements of the limbs rela- Stable supine position disrupted control over the muscle tension in the cer- tive to the shoulder girdle and the (based on a prematurely born vical section of the spine and in the shoulder girdle, child) pelvis. The reclination of the head delayed segmental extension of the spine, is a congenital physiological hyper- difficulty with food intake, lordosis of the cervical section of difficulty with sucking, swallowing, and breathing.

SUMMARY light to 4-5; medium to 6-7; and Conflict of interest: none declare high to 7 abnormal reactions (along- Neurokinesiological diagnostics and side a deeply disrupted control over therapy, regardless of whether neu- the muscle tension). a study by G. Ba- References rological disorders are indicated at naszak found that only 50% of chil- 1. Meholjic A., Knor T. Cerebral Disorders of a perinatal interview or whether the Movement and Habilitation by Vojta Method. dren with a medium level of CCD disharmonic motor development Acta Inform Med 2011; 1: 32-36. displayed spontaneous normalisation, 2. Levitt S. Rehabilitacja w porażeniu mózgo- stems from other factors (e.g. ge- wym i zaburzeniach ruchu. Wyd. Lekarskie whereas the use of the Vojta method netic factors), can determine wheth- PZWL, Warszawa 2007: 153-160 [Polish]. increased the effectiveness of elimi- 3. Banaszak G. Rozwój niemowląt i jego zabu- er future rehabilitation is successful. nating the symptoms of a disrupted rzenia a rehabilitacja metoda Vojty. Alfa Me- The infant may display motor abnor- dica Press, Bielsko-Biała 2004: 41-78 [Po- CNS to about 95%. With no thera- lish]. malities as early as the first weeks of py, 71% of infants with a light degree 4. Surowińska J. Metoda Vojty. Wyd. Lekarskie life. Therefore, a thorough observa- PZWL, Warszawa 2013: 35-70 [Polish]. of CCD show improvement, where- 5. Vojta V., Peters A. Metoda Vojty. Gry mię- tion of the infant’s spontaneous mo- as the use of therapy increases the śniowe w odruchowej lokomocji i w ontoge- tility, assessment of the eye contact, nezie ruchu. Fundacja Promyk Słońca, War- chances for removing a neurological szawa 2006: 87-211 [Polish]. and the presence of infant reflex- disorder to as much as 98%. Nine- 6. Orth H. Terapia metodą Vojty. 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