1 2009Haynes, Ritchie, Franjoine, McElroy Aspects of Typical Development Margo Prim Haynes, PT, DPT, MS, PCS Jan McElroy, PT, MA, PCS Mary Rose Franjoine,

2009 Haynes, Ritchie, Franjoine, McElroy

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Aspects of Typical Development

Margo Prim Haynes, PT, DPT, MS, PCSJan McElroy, PT, MA, PCS

Mary Rose Franjoine, PT, DPT, MS, PCSGail Rickie, OTR/L


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Organization

• Functional Activities (Behaviors)

• Control of posture and movement

• Status of individual systems


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NDT Enablement Classification Model of Health and Disability

Dimension Functional Domain Disability Domain

A. Body structure & functions

Structural & functional integrity

ImpairmentsA.PrimaryB.Secondary

B. Motor functions Effective posture & movement

Ineffective posture & movement

C. Individual functions Functional activities Functional activity limitations

D. Social functions Participation Participation restriction

+ Domains -

Dim

ensi

ons

From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82


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Newborn


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Newborn:Functional Activities (Behaviors)

• Breathes on his own• Turns head to clear airway• Finds food if it’s close• Eats and eliminates• Attempts to sooth self• Establishes bond with parents• Uses voice to communicate essential needs


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Baby Pictures!


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Newborn:Posture and Movement

• Bias toward flexion in the limbs• Weight shifts forward toward the face• Lower extremities free to move*• Phasic burst of extension• First attempt to control extension is in cervical

spine


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Baby Pictures


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Posture and Movement : Newborn

• Doesn’t lay completely on back in supine – rounded spine

• Alignment of rib cage & shoulder complex is elevated allows for hand to mouth activities

• Hand variety* • Pull to sit:


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Baby Pictures


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Newborn: Neuro-motor system• Stiffness ↑, cannot

grade changes• Apparent bias for

flexion• Muscle activation is

concentric phasic bursts

• Under-damped – Clonus & Tremors


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New Born: Musculoskeletal

• Muscles of flexion in a shortened state

• First efforts of cervical extension start to elongate anterior neck muscles

• No strength above fair ‘-’ (i.e. cannot move through range against gravity)


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New Born: Sensory• Proprioception

– More comfortable in flexed position– Deep pressure to oral region


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New Born: Sensory

• Vestibular– Semi-circular canals are functional– Receives input from head movements


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TactileHyper-responsive to tactile input…if overwhelmed will shut downMore adaptive to deep pressure…especially in flexion (i.e. swaddling)

New Born Sensory


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Newborn: Sensory• Vision

– Focal length is about 7”– Monocular (…receives info from one eye at a time)

• Auditory– Alerts to sounds– Can be easily overwhelmed

• Olfactory/taste– Discriminates olfactory input…finds mom by smell– Taste preferences…prefers breast milk


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Newborn: Respiratory

• Belly breather– Has no resistance to diaphragm pulling down

• Very rapid…over 100 cycles per minute• Very irregular and can be easily disrupted• Oral structures promote the production of “ma”

when distressed


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Newborn: Cardiovascular…

• Rapid heart beat…120-160 bpm• Can be irregular• Murmurs are common• Immature distal system…cold extremities


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One – Two Months


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One to two months:Functional Activities (Behaviors)

• Lifts head higher• Holds head up when supported in upright• Brings mouth to hand to soothe self• Suckles food• Engages others with facial expressions


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Baby Pictures


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Posture and movement : 1-2 M

• Age of (loss of physiological flexion):– Hypotonia– Asymmetry*– Disorganization

• Active movements in greater ranges


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Baby Pictures


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Posture and Movement: 1-2 M

• Efforts to lift head results in oral cavity opening up• Begin coordinating swallow with breathing• Sucking pads absorbing…pattern changes to

suckle– Tongue moves forward/backward and up/down with jaw– Starts to leak milk at corners of lips


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Posture and movement: 1-2 M

• Head elevates to 45º with extension through thoracic spine (end of 2 months)

• Hips positioned in flexion, abduction & external rotation

• Lateral borders of feet on surface (end of 2 months)• Supine & Prone: Asymmetrical postures• Pull to sit: “Increased head lag” • Astasia Abasia


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Baby Pictures


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Posture and Movement: 1-2 M• Head control changes with ability to lift head off

adult’s shoulder: in supported sitting not have stability• Shoulder girdle remains elevated• Forearms accept partial body weight as does the

ulnar border of the hand• Involuntary grasp and release• Awareness of object in hand ↑ by end of 2 months


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Baby Pictures


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One –Two Months

• Neuromuscular System• Musculoskeletal System• Sensory System• Respiratory System• Circulatory System


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Video Clip


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Neuromotor system: 1-2 m

• Decreased control/coordination of levels of stiffness • Inefficient controlled balance of flexion and

extension• Phasic bursts of extension throughout body• Brief sustained cervical extension• Extraneous movement observed• Synergy repertoire expands to include asymmetrical

patterns


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Musculoskeletal: 1-2 M

• Greater ranges of movement in cervical spine• Elongation of SCM, Scalenes and infra-/supra-

hyoids• Posterior weight shifts start to open anterior

chest wall


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Sensory: 1 – 2 M

• Great variability in child’s ability to maintain homeostasis

• Visual– Focal length increases to 10”– Acuity is 20/800 to 20/200– Dramatic increase in activity in the visual cortex


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Sensory: 1-2 M

• Auditory– Greater discrimination of auditory stimuli– Improved localization– Will pause to listen for responses

• Tactile:– Less sensitive to light touch


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Respiratory: 1-2 M

• Movement of head and weight on chest leads to greater space between sternum and humerus

• No activity of rib musculature yet• Respiratory pattern may look less stable

– Paradoxical breathing• Will start producing sounds with

movement…”pumps out” the sound


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Cardiovascular System: 1-2 M

• Heart rate is down to about 100-140 bpm• More stable pattern• Distal system has matured…extremities not as cold

or discolored


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Three – Five Months


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Functional Behaviors: 3-5 M• Observes the world in prone, supine and supported sitting• Rolls from stomach to back

– Accidental (4 months) to controlled (5 months)• Rolls from back to stomach (5 months)• Grasps toys with increasing refinement• Hands to midline to come toward the bottle• More successful soothing self• Communicates joy and fun with sounds…experiments with

sounds for play


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Baby Pictures


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Posture and Movement: 3-5 M• Age of Symmetry and midline orientation

– 3- 5 months– 5 months control developed : beginning to develop asymmetrical

control• Has active downward gaze with head up• Lateral weight shift

– 3 months…immature– 4 months…gets elongation on weight bear side– extension into lumbar spine– 4-5 months ….Elongation, with higher elevation leads to rolling from

prone to supine – 5 months… Rolling supine to prone


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Baby Pictures


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• Head in midline• Flexion, abduction and external rotation of LE’s

– Prepares feet for weight bearing• Antigravity flexion in supine develops

– 4-6 months: – plays with legs… reaching to knees, ankles and

feet


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Baby Pictures


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• Side-lying play develops– 4 months: flexion/extension balanced to allow side-lying– 5 months: play in side-lying


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• Sitting skills emerging: Progress toward independent sit– 4 months… Sit with extension to T6-T8– 4 months…Scapular adduction to reinforce upper body

antigravity activity in supported sit– 5 months …. Using UE support ….getting ready to let go!


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Baby Pictures


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• Pull to sit– 3 months…head control– 4 months…UE assist

• Fully active in pull to sit (end 5 - 6 months– No head lag throughout transition– Upper extremity assist– Active abdominals– Lower extremity preparation


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Baby Pictures


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• Stand with hips flexed behind shoulders• Significant change in structural alignment of oral

mechanism at 4 months


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Baby Pictures


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Three - Five Months: Systems

• Neuromuscular System• Musculoskeletal System• Sensory System• Respiratory System• Circulatory System


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Video


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Neuromotor system : 3-5 M• Coactivation in C & T spine segments allows ↑

symmetry• Opposing forces facilitate increased activation

flexion/extension• Synergy explosion

– Coactivation yields elongation of WB side and axial rotation of upper body

– ↑ flexion/extension includes activation of serratus – Allows for EROT of shoulder and dissociation

between shoulders• Graded control of stiffness• Increased damping


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Musculoskeletal : 3-5 months

• Increased extension into lumbar spine elongates upper abdominals, hip flexors, latissimus and intercostals– Rolling to sidelye elongates latissimus dorsi and

rotator cuff– Thoracic rotation with increased sternal/clavicular

mobility elongates intercostals• Tongue base musculature elongated• F+ to G- upper body and shoulder girdle strength• Antigravity pectoral muscles• Antigravity cervical flexion at end range• Slight active elbow flexion


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Sensory : 3–5 months• Proprioception

– Deep pressure into abdomen, upper extremities and anterior thighs

• 3 month…forearm/ulnar border allows for increased grasp and discrimination

• Vestibular– Lateral weight shifts and rolling increases awareness

of movements in diagonal planes• Tactile

– Light touch to mouth, chest, hand-hand, and foot-foot– Tactile discrimination…ticklish


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Sensory: 3-5 M • Vision

– Downward visual gaze– Distance vision across room– Can follow another’s line of vision

• Emergence of mutual engagement• Auditory

– Discriminates pitch and intensity…understands power of voice

– Looks for speaker


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Respiratory System: 3-5 M• Rib cage equals one-half of the trunk• Activation of abdominals resists the diaphragm

– Increased depth of inhalation and longer voice production

• Can breathe through mouth as well as nose• Synchrony of respiration is not disrupted by movement• Voicing still derives from moving body

– Moves body intentionally to produce voice• Expansion of the chest (not from intercostal activity); belly

breathing still predominates


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Cardiovascular: 3-5 M

• Cardio– Increased heart size…decreased heart rate

• Skin– Changes in oral mechanism increases drooling…more

“rashy”


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Questions anyone?

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Six Months


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Baby Pictures


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Posture and Movement: 6 M• Prone weight shift is more caudal• Full elongation of trunk yield dissociation of LE’s• Turns head and reaches out to side

– More active scapula and increase palmar input– Supports with one hand while manipulating

with other• Active rolling with LE dissociation


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Baby Pictures


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Six Months: Functional Behaviors (Activities)

• Props in prone on extended elbows

• Plays in prone…entertains self

• Rolls back and forth• Independent Sitting• Sustains side lying• Improved UE control for

reaching

• Complete pull to sit• Emerging object

appropriate schema• Starting to eat solids• Starting to drink from cup• Babbles and starting to

imitate


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Posture and Movement: 6 M• Holds antigravity flexion in supine

– Plays with legs…reaches to knees, ankles, feet– 5 months…shoulders off surface– 6 months…pelvis of surface

• Fully active in pull to sit– No head lag throughout transition– Upper extremity assist– Active abdominals– Lower extremity preparation


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Baby Pictures


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Posture and Movement - 6 months• Progression toward independent sit

– 5 month…using UE support– 6 month…active gluteals allow stable sit without support

• Active oral exploration (third hand)– Munching assists with eruption of teeth

• Stand with support…initiates bouncing


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Baby Pictures


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Video


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Neuromotor System: 6 M• Control of extension progresses past hips • Increases isolated control to initiate, sustain and terminate

muscle activation in UE’s• Control of shift between co-activation and reciprocal inhibition

progresses to LE’s, allowing for bouncing in stance• Control of flexion in trunk to counterbalance extension allows

for rotation• Prone weight shifting facilitates dissociation of the LE’s• Improved gradation of stiffness


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Musculoskeletal System: 6 M • Quadratus lumborum, gluteus medius and tensor fascia lata

elongated from weight shifting through the pelvis• Full ROM present at hips, but hip flexors are still tight• Lengthening quadriceps and hamstrings• Elongation of thenar eminence• Muscles of neck, trunk and hip flexors/extensors are at

least of F strength• Oral exploration yields increased range of lips/cheeks

musculature


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Sensory System: 6 M • Proprioception

– Deep pressure in lateral trunk, distal segments– Improved kinesthetic awareness…doesn’t need to watch

hand when reaching• Vestibular

– Vestibular stimulation strong from rolling and bouncing– Increased desire to be upright…resists laying down– Body begins to respond in anticipation of falling


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Sensory System: 6 M • Vision

– Orientation changes because of sitting– Eyes direct hands for reaching – Dissociates eye-head movements– Attends to small objects– Looks for fallen objects

• Auditory– Improved discrimination…recognizes name– Can pin-point mom’s voice from group– Engages in familiar auditory games


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Respiratory System: 6 M

• Intercostals participate in breathing• Increased tidal volume…decreased rate down to 60

bpm• Able to increase force of exhalation…allows for

screaming and squealing• Can interrupt breathing to take sequential swallows• Can use breath holding for postural control


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Cardiovascular System: 6 M• Cardiovascular

– Continues to develop• Gastrointestinal

– Solid foods frequently introduced…system is learning to adapt to varied nutritional sources

• Perception/memory/cognition– Evolving object permanence– Learning from mistakes…problem solving new motor

strategies


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Here come our Babies!!

Documents

1 2009Haynes, Ritchie, Franjoine, McElroy Aspects of Typical Development Margo Prim Haynes, PT, DPT, MS, PCS Jan McElroy, PT, MA, PCS Mary Rose Franjoine,