Understanding the role of the cervical spine Understanding the role of the cervical spine and upper extremities in the synactive and upper extremities in the synactive development of the preterm and term development of the preterm and term

infantsinfantsLooking into the FutureLooking into the Future

John Chappel, MA, PTSan Jose, California

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- Anne Geddes- Anne Geddes

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In the fields of observation chance favors the In the fields of observation chance favors the prepared mind.prepared mind.

Louis Pasteur, 1822-1895Louis Pasteur, 1822-1895

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The ELBW infant lives in a world of "co-morbidities", The ELBW infant lives in a world of "co-morbidities", which is in essence is a "network" of dysfunction. A which is in essence is a "network" of dysfunction. A non-Cartesian analysis of these dysfunctions is what non-Cartesian analysis of these dysfunctions is what today is all about.today is all about.

THEY ARE NOT CO-MORBIDITIES BUT A WEB OF THEY ARE NOT CO-MORBIDITIES BUT A WEB OF SYNACTIVE DYSFUNCTION INVOLVING THE WHOLE SYNACTIVE DYSFUNCTION INVOLVING THE WHOLE ECOLOGY OF THE INFANT.ECOLOGY OF THE INFANT.

nothing nothing lessless than that than that

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Thoughts on "Co-morbidities“Thoughts on "Co-morbidities“

You cannot have "co-morbidities" without stress. You cannot have "co-morbidities" without stress. Stress makes every human condition worse. Stress is a Stress makes every human condition worse. Stress is a force that causes distortion and reaction of a "system" force that causes distortion and reaction of a "system" or function. or function.

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Thoughts on "Co-morbidities“Thoughts on "Co-morbidities“

Many of the "co-morbidities" we see in ELB infants is Many of the "co-morbidities" we see in ELB infants is acute inflammation and stress becoming chronic. You acute inflammation and stress becoming chronic. You can't have inflammation without stress.can't have inflammation without stress.You can't have pain without inflammation.You can't have pain without inflammation.

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Any movement or change in postural tone demands Any movement or change in postural tone demands a requisite change in physiologic equilibrium. a requisite change in physiologic equilibrium. These must be facilitated automatically by the These must be facilitated automatically by the infant or maladaptation occurs .infant or maladaptation occurs .

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Movements made in the direction of gravity acquire Movements made in the direction of gravity acquire added impetus and sensory input that makes added impetus and sensory input that makes them hard to change once acquired - for better or them hard to change once acquired - for better or worse.worse.

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Many postures and movements of the ELBW infant’s Many postures and movements of the ELBW infant’s are concerned with using compressive joint forces are concerned with using compressive joint forces (CPP) to “bond” with gravity to achieve and hold (CPP) to “bond” with gravity to achieve and hold stable postures - at the expense of physiologic stable postures - at the expense of physiologic control. Remember Selye’s GAS.control. Remember Selye’s GAS.

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Wisdom consists of the anticipation of Wisdom consists of the anticipation of consequencesconsequences

Norman Cousins 1912-1990Norman Cousins 1912-1990

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- Anne Geddes

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Need a quiet baseline and good alignment for cranial Need a quiet baseline and good alignment for cranial nerve functions like swallowing, balance, pharyngeal nerve functions like swallowing, balance, pharyngeal competencies, to occur.competencies, to occur.

Because all soft tissue anteriorally at TMJ have to adapt Because all soft tissue anteriorally at TMJ have to adapt to structural dysfunction in the cervical spine.to structural dysfunction in the cervical spine.

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Swallowing and Occlusal PatternsSwallowing and Occlusal Patterns

Audience ParticipationAudience ParticipationHead straight, open and close mouthHead straight, open and close mouth

Now Side BendNow Side BendNow Side Bend and RotateNow Side Bend and RotateNow ExtendNow Extend

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Thoughts on Co-morbiditiesThoughts on Co-morbidities

Abnormal alignment, postures and movement changes Abnormal alignment, postures and movement changes the body's ability to move the body's ability to move allall fluids to some degree. fluids to some degree. This creates fluid stosis which This creates fluid stosis which createscreates and exacerbates and exacerbates allall inflammation. During the course of today keep inflammation. During the course of today keep thinking "how can I help this baby manufacture, move, thinking "how can I help this baby manufacture, move, excrete and re-claim its precious bodily fluids?“excrete and re-claim its precious bodily fluids?“

This is the essence of physiologic synactive careThis is the essence of physiologic synactive care

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ThoughtsThoughts

It's not "Fight It's not "Fight oror Flight“ Flight“

It's "Flight It's "Flight andand Fight“ Fight“

And sympathetic tone always wins, which, sooner or And sympathetic tone always wins, which, sooner or later, in the ELBW always becomes the problem and later, in the ELBW always becomes the problem and not the solutions.not the solutions.

How do you help your baby "FLOW" in the NICU.How do you help your baby "FLOW" in the NICU.

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Scapula – Omo Scapula – Omo

The key to making the chest work is restoring the The key to making the chest work is restoring the motion to the scapula and clavicle.motion to the scapula and clavicle.

Until this is done, full range of the ribcage or humerus Until this is done, full range of the ribcage or humerus cannot happencannot happen

(L. Rex, URSA, 09)(L. Rex, URSA, 09)Amen! 18 muscles attach to the scapulaAmen! 18 muscles attach to the scapulaLevator scapula attaches to atlasLevator scapula attaches to atlas

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Ribcage / ThoraxRibcage / Thorax – changing ANS tone – changing ANS tone

TT11 – T – T55 fibers ascend in the symp cervical chain to fibers ascend in the symp cervical chain to synapse in; SCG, MCG and ICG.synapse in; SCG, MCG and ICG.

This is their sympathetic feedThis is their sympathetic feed

TT22 – T – T66 overlap heart, lungs, stomach et al. So alter ANS overlap heart, lungs, stomach et al. So alter ANS activity by (decrease symp tone), treating here activity by (decrease symp tone), treating here normalizes somatic – visceral tone.normalizes somatic – visceral tone.

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The role of the upper symp chain ganglia is to relay The role of the upper symp chain ganglia is to relay vasoconstrictor impulses to the pulmonary blood vasoconstrictor impulses to the pulmonary blood vessels and upper limbs. Saluting, Airplane, and vessels and upper limbs. Saluting, Airplane, and clasp, fingersplay, HTM etc, etc.clasp, fingersplay, HTM etc, etc.

UE Postures to change Pulmonary Physiology?UE Postures to change Pulmonary Physiology?

With and Without Resp Pause or change in Rate? With and Without Resp Pause or change in Rate?

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Vagal Treatment Control – so many possibilities Vagal Treatment Control – so many possibilities

Right recurrent laryngeal nerve branches off to Right recurrent laryngeal nerve branches off to ascend ascend between the esophogus and trachea.between the esophogus and trachea.

One monitors AirOne monitors AirOne monitors FoodOne monitors FoodPulmonary an GI functions are Pulmonary an GI functions are constantlyconstantly tied together tied together

especially here with L vagus in a plexus on the esophogus.especially here with L vagus in a plexus on the esophogus.Remember swallowing smoothness pharnygeal arches 4 and Remember swallowing smoothness pharnygeal arches 4 and

6!6!

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Treating Sympathetic Tone Treating Sympathetic Tone

Cardiac Cardiac TT11 – T – T55

Pulmonary Pulmonary TT22 – T – T66

DigestiveDigestive TT55 – T – T99 (at least) (at least)

The Right Vayus is 80% Motor and 20% SensoryThe Right Vayus is 80% Motor and 20% SensoryMotor changes tone Motor changes tone andand produces substances. produces substances.

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When a system is stressed it adapts by ultimately When a system is stressed it adapts by ultimately changing shape to assist at all levels with the changing shape to assist at all levels with the balance and flow of resources and energies first.balance and flow of resources and energies first.

If an infant is placed in a stress situation where rigid, If an infant is placed in a stress situation where rigid, incorrect, or ineffective compensatory incorrect, or ineffective compensatory movements are selected (or dictated) then movements are selected (or dictated) then maladaptation in all maladaptation in all areasareas of it’s life process will of it’s life process will occur.occur.

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Compliance and BPDCompliance and BPD

The change between a high compliance chest wall The change between a high compliance chest wall (Basilar vs. Apical, Left vs. Right) and low (Basilar vs. Apical, Left vs. Right) and low compliance will occur overnight, over days, over compliance will occur overnight, over days, over weeks but it will occur. weeks but it will occur.

ButBut if you are not evaluating it and treating it if you are not evaluating it and treating it allall your your respiratory care, by definition, will be at best respiratory care, by definition, will be at best maladaptive, at worst incomplete.maladaptive, at worst incomplete.

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Chronic Lung DiseaseChronic Lung Disease – “Does anyone really know – “Does anyone really know what time it is?” Chicago ’70.what time it is?” Chicago ’70.

The single fundamental short coming of BPD care The single fundamental short coming of BPD care (“(“neoneo” and “” and “paleopaleo”) is that we ”) is that we nevernever take note on take note on how and how and wherewhere the infants chest wall compliance the infants chest wall compliance affects the respiratory process.affects the respiratory process.

How do you account for this in your Positioning and How do you account for this in your Positioning and Developmental Care?Developmental Care?

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Thorax / RibcageThorax / Ribcage

Exhalation results when the diaphragm and Exhalation results when the diaphragm and intercostal muscles relax and elastic recoil of the intercostal muscles relax and elastic recoil of the rib cage and lungs expel the air (COrib cage and lungs expel the air (CO22). Shuts off ). Shuts off quickly to generate recoil.quickly to generate recoil.

Inspiration & Expiration are completely different. Inspiration & Expiration are completely different. So is crying.So is crying.

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We grow up in response to the way gravity pulls us We grow up in response to the way gravity pulls us down. So gravity determines our shape whether we down. So gravity determines our shape whether we are trees, or children, or elephants. Gravity is are trees, or children, or elephants. Gravity is insatiable, it never let’s go.insatiable, it never let’s go.

K.C ColeK.C ColeFirst You Build a CloudFirst You Build a Cloud

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It is a well known fact that we see the faults in It is a well known fact that we see the faults in others’ work more readily than we do in our others’ work more readily than we do in our own.own.

Leonardo DaVinci 1452-1519Leonardo DaVinci 1452-1519

The key to being an impeccable clinician in the NICU is The key to being an impeccable clinician in the NICU is concatenate your caregiving into the realm of concatenate your caregiving into the realm of individual synactive care for individual synactive care for eacheach and and everyevery infant infant you treat – no matter who you are. There are no you treat – no matter who you are. There are no excuses anymore, NIDCAP.excuses anymore, NIDCAP.

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Everything mattersEverything matters

Dr. H. AlsDr. H. Als

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