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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 irreg- ularities 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, spontane- ous 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 de- velopment 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 ro- zwoju 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
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