BABY STEPS: BUILDING YOUR CASE FOR EARLY INTERVENTION

LYNN GEYER, PT, DPT COVENANT HEALTHCARE PEDIATRIC SYMPOSIUM 2016 EARLY INTERVENTION 0-18 MONTHS “WAIT AND SEE”

• “Wait and see” model has no research behind it, early intervention does • This belief encourages multiple myths: 1. Motor skills are automatic 2.Children will always catch up and/or “grow out of it” “WAIT AND SEE”

• Skill are expected at certain ages, but don’t get hung up on the skill, focus on the musculoskeletal-neurologic reasons for the skill • If positioning/skills are delayed, all skills after will be delayed equally in weeks or more BUILDING BLOCKS

Natural progression between skills, when one is attained, it builds on the next –Prone lifting of head and UE extension  Quad –Reaching across midline  Throwing a ball –Half kneeling  Stair Management BUILDING BLOCKS

When foundational blocks are lost between 0-18 months, children are consistently less likely to keep up with their peers for years after BUILDING YOUR CASE

• Breaking down to the basics of the body’s many systems • Evaluating reasoning behind concerns • Making a plan of care based on the physiological things you can change, improve, and prevent damage EVALUATION LISTENING

• Listening to what is said and not said during subjective questioning –Prenatal, perinatal, and postnatal history –Medical history (self and family) –Positioning –Current mobility –Feeding –Temperament BABY HOLDING DEVICES

• Babies are set up for failure, adults LOVE comfy furniture! POSITIONING

• Sleeping • Play • Feeding • Relaxation • Tummy Time TEMPERAMENT

These signs say “time out”; These may be signs your your baby needs a break: baby is ready to interact: • Looking away, glassy-eyed, • Quiet, alert state. Eyes are stressed look. opened and focused. • Limp body. • Relaxed; not too stiff or • Stiffening (pushing body limp. out straight). • and legs are tucked • Yawning, falling asleep. in. Hands are at mouth. • Hiccups, spitting up. • Some smiling (by about six weeks corrected age), and eventually cooing. HEAD SHAPE AND APPEARANCE

• Shape –Plagiocephaly – – • Fontanel size • Symmetry

BODY SYSTEMS OF FOCUS

• Musculoskeletal • Neurologic • Integumentary • Cardiac • Respiratory CARDIAC AND RESPIRATORY

• Heart Rate • Oxygen saturation and breathing rates • Endurance in positioning and movement INTEGUMENTARY

• Skin integrity • Skin folds • Temperature • Coloring • Hair and nails NITTY-GRITTIES: MUSCULOSKELETAL AND NEUROLOGIC

• Orthopedics • Neurologic –Strength –Motor Patterns –ROM –Reflexes –Posture –Tone –Skeletal Formation –Vestibular HOW TO ASSESS STRENGTH? MUSCLE FIBERS

• Type I – Slow twitch – Slow Contraction – 100 milliseconds to peak power • Type IIA – Fast twitch – Fast contraction speed – 50 milliseconds to peak power • Type IIB – Fast twitch – Very fast contraction speed – 25 milliseconds to peak power TYPE I (SLOW TWITCH)

• Slow contraction • Efficient at using oxygen • Continuous, extended muscle contractions for longer periods –Long time before fatigue, can use for hours • Good for high repetition, long activities –Endurance –Postural muscles • Generate low power/force/speed production TYPE IIA (FAST TWITCH)

• Fast contraction • Prone to fatigue • Bursts of energy for strength and speed –Jumping –Jogging • Short term use –Less than 30 minutes of activities –Phasic muscles • Generate high power/force/speed TYPE IIB (FAST TWITCH)

• Very fast contraction • Short term use –Less than 1 minute • Very high power/force/speed FIBERS

• So what does it all mean? • Training specific types and knowing how tone affects muscles – If you want more use of type I fibers, your tasks must be longer tasks, maintaining a position longer, slow tasks • Maintaining tall kneeling – If you want more use of type IIA or B fibers, your tasks should be short, quick reps, involve dynamic movement and more indicative of traditional strength training • Squat<>stand activities Postural Muscles Phasic Muscles – Pectoral • Middle, lower trapezius – Levator • Serratus Anterior – Upper Trapezius • Triceps – Biceps • Supraspinatus – Scalenes • Infraspinatus – SCM • Deltoid – Masseter • Wrist and Finger Extensors – Temporalis • Thoracic Erector Spinae – Wrist and Finger Flexors • Rectus Abdominis – Cervical and Lumbar Spinae • Transverse Abdomins – Quadratus Lumborum • Quads – Hamstring • Gluteals – Illiopsoas • Tibialis Anterior – Rectus Femoris • Toe Extensors – Adductors • Peroneals – Piriformis – Gastroc-Complex NEUROMUSCULAR TONE

• Tone is the tension in a muscle when stretched and when static • Hypotonicity • Hypertonicity • Spasticity vs Rigidity HYPOTONIA

• Motor nerve control loss, but diagnosing why is the difficult part and can be very unsuccessful in obtaining an official diagnosis • Muscle never fully contracts, so relaxation phase of the muscle occurs more often and joints are loose and stretchy • Not enough slow twitch muscles ASSESSING LOW TONE

• Positioning – Supine: frog legs, UEs to the sides of body, flattened trunk – Prone: unable to lift their head or use of UE support – Sitting: Flexed legs, wide base, external rotation with abduction on the lateral surface, arms extended at sides of body, slumped posture, neck flexion, increased lumbar /rounding of the back, W sitting – Standing: Limp arms, flexed , wide BOS, refusal to bear weight ASSESSING LOW TONE

– (Sunken chest, hollowed chest) – Plagiocephaly, (flat areas of the head, facial asymmetry, loss of hair) – Hyper-flexible – dislocation – Pull to sit (Should feel infant pulling back against traction) – Vertical suspension (should feel the muscles stabilize, head erect) – Horizontal suspension (wiggling to maintain head erect) – Umbilical hernia (weak abdominals) – Decreased reflexes – Slow integration of primitive reflexes ASSESSING HYPOTONIA

• Falling, “clumsy,” poor balance • Drooling • Constipation (weak abdominals) • Poor feeding/nursing • Speech difficulties/delays • Decreased activity tolerance • Leans on objects • Poor attention (cannot splint attention between two tasks) • Slow reactions, can’t turn their muscles on for use in activities or protective extension • Difficulties with transitioning from position to position HYPERTONIA

• Muscles are on all the time and/or the nerves are constantly telling the muscles to do something • Energy expending due to constant muscle spindle excitability • Thought to be strong, but rigidity to maintain a position does not contribute to strength of muscle activity • Upper motor neuro lesion with injuries to the CNS (SC, brain stem, motor cortex) ASSESSING HYPERTONICITY

• General: Fixing or stiffening of their muscles at the trunk (rigid trunk without rotation), fisting of hands, movement is rigid without rotation • Positioning – Supine: Extended joints at the extremity joints, UEs abducted away from body and midline – Prone: unable to lift their head or use of UE support vs extended on hands with minimal change in trunk positioning and head/neck in neutral or extreme extension – Sitting: Extensor pattern, tilting of the pelvis into extreme directions, extended legs, Standing: Hyperextension of the knees, plantarflexion of the ankles, rigid trunk, extended and abducted UEs REFLEXES

• Primitive reflexes –Reflexes to help with survival –Motor Response or an action the body takes in response to sensory input and is involuntary • Deep Tendon Reflexes SKELETAL FORMATION

• Weight bearing develops and forms muscles, bones, which impact all other systems of the body (vestibular, cardiac, etc) • Assessment of 0-18 months will be the most telling with muscle strength, posture of standing and sitting, and hip joint formation POSTURE

If our posture spoke, what would it tell us? HIP LAXITY/SUBLUXATION/DISLOCATION

• Ortolani Maneuver: the contralateral hip is held still while the thigh of the hip being tested is abducted and gently pulled anteriorly. The sensation of instability or “clunk” is positive • Barlow Maneuver: adducting the hip while pushing the thigh posteriorly. If the hip goes out of Ortolani maneuver Barlow the socket, it is called Maneuver “dislocatable” and the test is termed “positive.” • Skeletal forces on the hip due to lack of ROM, atypical muscle forces, contractures of hip adduction and flexion • Non-standing/ambulating children with and without low tone, the acetabulum does not grow to the correct depth and without standing dosing in both static and dynamic ways, lead to poor hip positioning ASSESSING FEET, ANKLES, KNEES

• Normal Development –Arch development – –Ankle pronation – valgus, varus SPECIAL CASE: PREEMIES

• Preemies are starting off development of muscles at the week of gestation born • Expectations vary among therapists, but often a rule of thumb is we adjust for 34 weeks or earlier • Muscle fibers develop in each area of the body at certain times of gestation; with preemies, we have to wait for those weeks to develop and it is a much slower rate of development

Questions?