pediatric rehabilitation recovery

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LA TIKA ROY FOUNDATION

2010

Paediatric Rehabilitation Therapy Course Handbook for interdisciplinary therapy

Nalin Kumar (PT)

Arju Bala (PT)

4 / 3 A , V A S A N T V I H A R E N C L A V E , D E H R A D U N , U T T A R A K H A N D

16- 27 August 2010

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Preface

The course is developed by Latika Roy Foundation, an NGO in Dehradun. The Foundation provides therapy, education, vocational training, counselling, rights based assistance, and of course play time to children with and without special needs. Our projects continue to evolve and touch the lives of individuals, their families, and the community in Dehradun and beyond. As there is a scarcity of interdisciplinary professionals working in the area of child rehabilitation, this course aims to provide skills to therapists (PT, OT, and SLT) in the area of Paediatric Rehabilitation.

Aim of the course

To provide skills to therapists in the area of Paediatric Rehabilitation; to make them well equipped with concepts of child development and to provide them tools for assessment and therapy which are based on evidence based practice and recent advances in the area of paediatric rehabilitation.

Brief introduction to Latika Roy Foundation

Latika Roy Foundation strives to make Uttarakhand, India, and the entire world a more inclusive place for all people regardless of ability, age, race, creed, or socio-economic background. Aware of the power of individual, we believe that each one of us should have a voice in our community, access to what we need, and respect from those around us. The foundation began working in 1994 as a space that featured arts and crafts, music, dance and sports all under one roof. Inspired by our success over the years, we have grown to a multi-tiered organisation featuring educational programs for babies, children and adults.


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Acknowledgement

The content has been developed with the great help and support of many interdisciplinary professionals working/attached with Latika Roy Foundation. The course content has also been developed with meticulous research from numerous books, journals and online resources. We extend our thanks to all children, family members, staff members, resource persons for their contribution towards the course. Considering the high professional level of the participants in the course we expect this course to be highly interactive and we expect that this will help build the skill levels of all who are related to the course. We offer our gratitude to participants for their participation in the course. Although all contents have been developed with some care and peer-review, chances of error has not been ruled out. We are thankful to the resources available online and this information in used for training purpose only. We would appreciate all feedback about errors or suggestions that would help make future editions of this handbook more robust and factually correct.

Resource Persons 1. Dr. Sebastin Gruschke (MD), Netherlands, Family and Child Physician, Latika

Roy Foundation 2. Dr. Ritu Srivastava (PhD), PhD Psychology, B.Ed. Special Education, Child

counsellor and Clinical Psychologist 3. Dr. Aarti Nair (PT), Clinical Physiotherapist 4. Anne Bruce (SLT), Based in UK, Volunteer and Resource person with Latika

Roy Foundation 5. Barbara Angert (OT), USA, Volunteer and Resource person with Latika Roy

Foundation 6. Pushpa Painuly, Vice Principal and Head of Department Speech and

Language, Karuna Vihar School 7. Dr. Nalin Kumar (PT), Physiotherapist LRF 8. Dr. Arju Bala (PT), Physiotherapist LRF 9. Deepak Pandey (B.Tech., PMP), COO - LRF


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Contents

S.No Topic Page No

1 Theory and Principles of child development 6

2 Essential milestones on child development 11

3 Gross Motor Milestones 13

4 Sequence of Postural Development 20

5 II a. Reflexes 22

6 II b. Role of reflex in development 24

7 II c. Contribution of Reflexes 30

8 II d. Development of Grasp 33

9 III. High Risk Infants 35

10 IV. Paediatric Neurological Assessment 38

11 V. Rehabilitation 42

12 VI. ICF

44

13 VII. Goal making in early intervention therapy 45

14 VIII. Sensory Processing Disorder Checklist 47

15 IX. Oromotor Rehabilitation 66

16 X. ADLs of Children with disability 84

17 Bobath Concept- Techniques of Proprioceptive and Tactile Stimulation

85

18 XI. Neuro Developmental Therapy(NDT) 91

19 XII. Conductive Education 105

20 XIII. Play 106

21 XIV. Biological and Physiological importance of various postures

108


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22 XV. Wooden furniture/equipments used in therapy 109

23 XVI. Dos and Donts in CP 113

24 XVII. Checklist

Chair cum standing frame

115

25 XVIII. Child Development Worksheet 119

26 XIX. Internet Resources 124


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I. Theory and Principles of child development

There are numerous theories on child development.

To understand child development we need to understand the meaning of development. Development means change in functional competence over time. A childs motor development is an adaptive change towards movement and competence throughout the life span. Competence means skilful mastery of the current skill and transition to the next skill. For a child to learn movement she would need motor control and movement coordination.

Child Development= Nature+ Nurture

Maturation+ Learning= Child Development

Task Individual Environment Performance demands

Anatomical

Opportunity for practice

Movement pattern formation Physiological Encouragement /motivation

Degrees of freedom Biomechanical Instruction Perceptual Environmental

context

Phase/Stage theory views development as a product that: Progresses from simple to complex Is sequential and orderly in nature Builds skill upon skill Varies in rate from person to person Requires proficiency in fundamental skills prior to using them as complex skills


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Concluding Concept: Motor Development Is Age-related but Not Age-dependent References

1. David L. Gallahue, Indiana University, USA


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I a. Principles of Development

Development is a continuous process from conception to maturity; for example, for a child who is 7 months old, one has to observe not only whether she can sit, but how she sits, and the degree of maturity she has developed in it.

1. Development depends on maturation and myelination of the nervous system. Until myelination has occurred no amount of practise can make a child learn the relevant skill.

2. Certain primitive reflexes anticipate corresponding voluntary movement and have to be lost before the voluntary movement develops. For example, walking reflex and grasp reflex are present in the newborn period and disappear after some time; reciprocal kick reflex disappears before walking

3. The sequence of development is the same for all children, but the rate of development varies from child to child. e.g. the child has to learn to sit before he can walk, but the age at which children learn to sit and walk varies considerably.

4. Cepahalo- Caudal (head to toe) - Which means the child development follows the sequence from head to toe. First the child learns to control the neck movements and then the child control proceeds to the trunk and later the motor development of legs and toe occurs.

5. Radio- Ulnar (Radius to Ulna)- First the child uses much of the movements of the radial side of the wrist and then proceeds to the Ulnar side. The child learns Radial grasp of objects first and then the Ulnar.

6. Proximal to Distal- The parts which are towards the bodys central line develop first and then the distal part of the body develops i.e, the development of head, trunk and pelvis happens before the development of shoulders, hands, finger and toes.

7. Medio- Lateral- Body parts which are located medial have their development first and then followed by lateral body parts.

8. Gross to fine (Gross movements to precise movements) - Child initially learns gross movements (neck control, sitting, walking) first which precedes the fine movements (grasp, writing, feeding, jumping etc.)

9. Simple to complex- The child learns simple movements and then with practice the child learns the complex tasks. ( Firstly the child learns to hold toy- then pencil- then scribbling lines- then writing alphabets or copying shapes)


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10. Maturation to learning- When the child experiences the movements again and again, the child registers the movements as memory and then is able to utilize it in a learned behaviour.

References:

The Normal Child Development: Ronald S.Illingworth: Chapter-12; The normal course of development


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2. Essential Milestones of Child Development

Stages of Gross & Fine Motor Skill Development:

Age: Gross Motor Skills: Fine Motor Skills:

Month 1 Can lift chin slightly Hands fisted/reflexive grasp

Month 2 Wobbly head while sitting Swipes toys with /hands

Month 3 Holds head steady in sitting

Rolls back to side

Puts weight on arms while on tummy

Hands open

Grasps/holds an object

Hands play at midline

Month 4 Sits on propped arm

Rolls tummy to side

No head lag seen when pulled to sit

Reaches with both arms/hands

Brings fingers/hands in mouth

Squeeze grasp emerging

Month 5 Rolls tummy to back

Wiggles few feet forward

Pushes up with arms while on belly

Sits propped on hands

Reaches with good aim

Month 6 Sits independently for a brief period

Sits in a highchair

Rolls over both ways

Reaches precisely and grasps objects

Transfers toys from hand to hand

Bangs a cup on a table

Month 7 Sits unsupported for ~30 seconds

Rocks on all fours

Pivots in a circle while on tummy

Crosses midline when reaching

Uses whole hand to rake in objects

Thumb to finger grasp emerging

Month 8 Transitions tummy to sit

Crawls forward

Reaches while on tummy

Bangs cubes together

Uses a three-fingered grasp


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Month 9 Transitions sit to tummy

Pulls to stand while holding on

Creeps on all fours

Stands while leaning on furniture

Uses thumb to index finger grasp(crude)

Crude release of objects

Drops toys and objects

Points index finger

Month 10 Cruises along furniture

Stands unsupported briefly

Transfers from crawl to sit

Pokes with fingers

Uses thumb to index finger grasp(precise)

Stacks objects

Month 11 Stands unsupported

Walks with hands held

Releases a cube at will

Removes pegs from a pegboard

Month 12 First independent steps

Stands unsupported~12 seconds

Assumes/maintains kneeling

Puts objects in a container

Releases an object precisely

Stacks two one-inch cubes

12-15 Months Walks independently

Creeps/climbs stairs

Tries to climb out of highchair

Squats to play

Kneels

Stoops and recovers

Throws objects

Places rings on a peg

Holds large crayon in fisted grasp

Pulls large popbeads apart

Builds a 2 block tower

Throws objects

References:

1. Harris County Developmental Inventory, Dr. Sears Baby Book, Hawaii Early Learning Profile

2. The Michigan Developmental Scales


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GROSS MOTOR DEVELOPMENT MILESTONES IN ALL POSTURES

Supine Posture

AGE TONE POSTURE MOVEMENT PATTERN / MUSCLES

REFLEXES USE OF HANDS

1-3 mon

Head, neck & trunk: hypotonicity Limbs: hyper tonicity

Keeps head to one side

Both arms & legs are flexed, knees apart

Sole of feet turn inwards

Keep hands closed (fist), thumb turn in

Large, jerky movements in limbs

Arms more active than limbs

Neck & Head control starts

Movmt. Becomes smooth & cont.

Open hands time to time

Rooting

Suckling

Grasping

Hand opening

Flexor withdrawl

Extensor thrust

Crossed extension

Tonic Lab. supine

Cardinal points

Starts opening hand from time to time

Starts bringing hand from side to midline

3-6 mon

Head: normal

Trunk: slight hypotonic

Limbs: slight hypotonic

Postural stability of shoulder girdle

Raises head to look at feet

Good head holding

Starts counterpoising the limbs in the air

Kicks strongly

Moves legs alternately

Can roll from side to side

Can bridge his hips off the surface (5m)

Tries to sit

Grasp

Moros

Startle

Neck righting

Primitive squeeze

Radial Palmar

Uses hands for grasp

Uses both hands, occasionally one hand

Brings hands together from sides into midline

6-9 mon

Head: normal

Trunk: normal

Limbs:

normal

Posture stability of pelvis

Can lie straight

Can turn his head easily

Child holds a leg up in air in order to grasp his foot with his hand

Supine to side lying

Try to sit from side lying

Rolling & rising sequence of motion

Raking movt.

Startle

Moros

Tilt reaction

Saving reaction

Try to grasp foot by hand

Manipulate toys

Begins to point at object with index finger

Pass toy from hand to hand

Release toys by dropping

9-12 mon

Normal tone Good postural stability:

Head & Neck stability

Shoulder stability

Very active and controlled movements of body & limbs

Pulls himself to sitting from side lying

Landaus

Pincer

Tilt reaction

Puts hands around bottle when feeding

Try to grasp spoon

Clapping


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Pelvic stability

Turns body to look sideways

Saving reaction Drops & throws objects

Shake toys to make noise

Takes object to mouth less often

12-18 mon

Normal tone Head in center or side (supine position)

Arms/Legs can be flexed or extended when in supine

As child has learnt to sit, stand and walk, he/she no longer prefers supine position

Landaus

Pincer

Tilt reactions

Saving reactions

Turn pages (thick) of books

Feeds himself with assistance

Likes throwing objects one by one

18-24 mon

Normal tone Lie (supine & prone)

Sit

Stand

Functional sitting and walking

Movements get more refined

Mostly voluntary movements

Landaus

Can lift objects, throw objects forcefully

Refined grasp and scribbling

2-5 yrs

Normal tone Use supine position to rest and sleep

Use supine position to rest and sleep

Fully functional

Voluntary movements

Further precision writing & drawing


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Prone Posture



1-2 mon

Limbs: hyper tonicity prevails in flexor muscles.

Head, neck & trunk: hypotonicity prevails / slack / no muscular tone.

Neonate: in prone, the baby promptly turns his head sideways, his cheeks resting on the tabletop. The buttocks are humped up, with the knees flexed under the abdomen. The arms are close to the chest with the elbows fully flexed.

1month - same with hands under the abdomen and arms & legs flexed, elbows away from body, buttocks moderately high.

Reflexive movements. Can flex upper limb and lower limb with greater suppleness.

Limited range, predominantly flexion.

Can raise his head to 45 from the plane of the bed.

0-2month- Gallants trunk incurvation.

1-4 months-

a) Cross- extension reflex.

b) Tonic -labyrinthine-prone.

c) STNR

Newborn: the primitive grasp reflex present.

1m. The reflex is still present.

2m. The reflex is less apparent and his hands are quite often open.

3-4 mon

Limbs: hypertonicity becoming hypotonicity leading to extension in upper limb and lower limb.

Head and trunk: hypotonicity becoming normal.

Lifts head and upper chest wall up in midline, using forearms to support & (often) actively scratching surface with hands; buttocks flat

Disassociation of head from shoulders; working against gravity

At 4 months: does swimming, flexing and extending all his limbs.

Raises himself on his forearms/ elbows and can raise his head to 45 and 90 from the plane of the bed

Strengthening of neck muscles

1-4 months-

a) Cross- extension reflex.

b) Tonic -labyrinthine-prone.

c) STNR

3mo-2.5 years: Landaus reflex

Grasping on contact, the child involuntarily grasps an object placed in contact with his hands.

5-6 mon

Limbs: normal tone. Head and trunk: very firm / further increase in tone.

Placed in prone, lifts head and chest wall up supporting himself on flattened palms and extended arms.

Hip-anchoring

Lying on his abdomen, he becomes an aeroplane, supporting his weight on his thorax; he raises his arms and legs.

Rolls from abdomen to his back.

Co-contraction of muscles in upper arm

4-6 months- Righting reactions-Amphibian.


6 month onwards: Tilt reactions

(General rule: Concavity on higher side)

Lying flat on his abdomen, the forearms are hyperextended in front of the infant and his hands flat on the ground. He cannot yet use them to play with but raises himself up on hands.

7-8 mon

Limbs: normal tone. Head and trunk: normal tone.

Placed in prone, lifts head and chest wall up supporting himself on flattened palms and extended arms.

Easily roles over in both directions (back to abdomen and abdomen to back).


Raise one hand from ground to take hold of a cube.

Passes cube from one


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Go from complete flexion in hips to mid-flexion

When lying on his abdomen, he can raise up his entire body on his hands and knees.

6 month onwards: Tilt reaction

7-12 month onwards: Four-point kneeling

Saving reactions

hand to other, bangs them together and on the ground.

Releases objects voluntarily with movmt. of whole hand.

Grasps an object between thumb and little finger.

9-10 mon


Crawling posture taking weight on hands and knees

Achieves sit from hands and knees: Side sitting, W sitting

Pivots body using limbs to right/left.

The infant tries to crawl on his stomach & progresses to walking on all fours (hands & knees).

He starts by going backwards.


6 month onwards: Tilt reaction

7-12 month onwards: Four-point kneeling

Saving reactions

Grasp objects between base of thumb and fore finger.

Pulls an object by string.

Likes to throw objects.

11-12 mon


Half kneels with hand supports

Rises to upright kneeling with hand supports

Bear-walk posture weight on hands and feet

Crawls reciprocally

Bear walk the infant walks more confidently on all fours (hands & feet).


Tilt reaction

4-point kneeling

Saving reactions

Grasp improves further. Can release objects with fine & precise movements.

Points to objects with forefingers.

15 months &above


Kneels unaided or with slight support in prone

Half kneels upright no support (against gravity, extension at the pelvis)

Inclined crawling- climb the stairs on all fours. Smoothly moving from ext/flex to co-contractions.

Knee walks forward


Tilt reaction

4-point kneeling

Saving reactions

Makes towers of 2cubes.

Turn pages of a picture book.


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Sitting Posture



Neonate

Limbs: hyper tonicity

Head, neck & trunk: hypotonicity

Held sitting back and head uncontrolled

Flexion in total body Grasp reflex

Hand opening

Foot grasp

Head righting

Primitive grasp reflex

2months

Limbs: hypertonicity becoming hypotonicity - extension in upper and lower limb.

Head and trunk: hypotonicity becoming normal.

Held sitting head remains upright for few moments but wobbles

Head and neck extended but control not present

Back flexed

Hips slight ext.

Automatic sitting protraction of shoulder girdle

Tracking occurs with eye but hand control not present

3months

Head and neck: normal tone

Trunk: Hypotonicity

Limbs: normal tone

Held sitting head & neck straight.

Back firm but lumbar region still weak

Head control in supine &prone position

Head & Neck extended to vertical

Lumbar kyphosis present

Increased extension of upper and lower limbs

Labyrinthine head & vestibular righting reflex

Clumsy reaching bilateral

Grasps objects placed in hand, thumb adducted

4-6

months

Tone is normal in head, neck, trunk &limbs

Postural fixation of head on shoulder girdle

Sitting with support, back straight, legs straight turning out and apart

Sitting on baby chair with back & sides supported or propped on a pillow support

Head & neck -extended/vertical

Hips extended

Legs extended

Sitting lean on both hands, forward with less support

Saving & propping reactions in forward direction

Reaching in all directions

Bilateral to unilateral reach

Thumb pressed in opposition

Ulnar/palmar grasp

Wrist flex./ext.

6-7 months

Tone is normal Postural fixation of trunk on pelvis

Sitting lean on hands

Lift one hand to play with toys

Head, neck extended

Back bent to flexion

Arms extended

Hips flexed, abducted & ext rotated

Saving & propping reactions in forward direction

Manipulate toys with one hand & use other hand for support

Unilateral reach & grasp

Beginning radial grasp


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Knees flexed

7-8 months

Tone is normal Sitting, reach in all directions; hand support sideways

Trunk more control so rotation is possible

Upper limb all movements, ext. in one arm, flex in other

Lower limb

Rotation in hip

Saving & propping reactions in sideways direction

Use hands to save in forward and side directions

Pats images of face in mirror

8-9 months

Tone is normal Sitting without external support, may use hand for support

Head, neck, trunk & upper limb variety of motions

Lower limb control improved

Full ext. of hip still not possible

Tilt reactions in forward, sideways & backward directions


Manipulation with both hands (bilateral & unilateral)

9-12 months

Tone is normal Turn to play, reach, no self hand support

Sitting to various positions round sitting, long sitting, side sitting, W sitting, cross legged, stool/chair sitting

Co-contraction of neck & trunk

Trunk/Pelvic disassociation

Hips - anchoring is complete; wt. shifting. rotation

Rising out of sitting and getting into all sitting positions

Tilt reactions in forward, sideways & backward directions


Point with index finger

Reach and grasp in all directions

Pick & place objects in & out of large container

1-5 years

Tone is normal Various postures can be attained Various muscle activities can be performed because of better control & coordination

Saving reactions completely developed

Hand manipulation is refined


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Upright Posture



0-3 months

Head, neck & trunk: hypotonic

Limbs: Flexor tone in lower limbs, extensor tone developing in knees

Trunk supported Plantigrade feet

Hip slight flexion

Knee extension

Ankle neutral

No pelvic stability

Flexor withdrawl

Crossed extension

Placing reaction

Automatic walk

No hand function

3-6 months

Head: normal


Limbs: slight hypotonic

Bears some weight

Trunk support is required

Hip extension

Knee hyper ext.

Ankle plantar flex.

Simultaneous contraction of opposing muscle groups started (co-contraction)

Positive supporting (3m)

Negative supporting (3-5m)

Foot grasp

Uses hands for grasp

Uses both hands, occasionally one hand

Brings hands together from sides into midline

6-9 months

Head: normal


Limbs:

normal

Stands with forearm leaning and pelvis support

When standing by holding- hips may flex, feet are flat

Hips both flexors and extensors contract simultaneously (co-cont)

Toes flexion

Placing reaction more predominant

Saving reaction

Use hands as support while standing

In saving, use hands for protection

9-12 months

Normal tone Pulls self to stand

Cruises using two hands

Stands, holds one hand & can reach in all directions with other

Can lift one leg

Reciprocal contraction of opposite muscle

Abduction & adduction of hips while cruising

Saving reaction Counterpoising

Saving

Both arms for holding

Support & bear weight for cruising

12-18 months

Normal tone Stands, stoops and recovers

Stands without support

Extension of hip, knee, ankle (neutral) while standing

Contraction of hip extensors of one limb & flexors of other limb while standing (1 limb)

Simultaneous contract. of

Tilt reaction trunk

Staggering forwards, sideways, backwards

Counterpoising without holding

Walking hand for support, 2 hand to 1 hand hold

Carry objects while walking

Use hand for rising

Support while stair


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Sequence of Postural Development

Propping- This is first posture that the child assumes in all fundamental postures. It is basically a preparation stage for the child to have an experience in the posture. So it means the child needs to experience propping in all the postures.

Head Free- After propping the child starts using his head neck to learn from the environment. The ability of the child to assume head control and perform the neck movements is said as Head free. The child needs to perform head free movements in all the postures as part of typical development.

flex/ext

Abd/flex/ext of hip while staggering

climbing

18-24 months

Normal tone Stand alone, runs

Turns (pivots)

Co-contraction of flex/ext

Reciprocal leg function while running (dissociation)

Rotation of hip & trunk while turning

Reciprocal limb movmt. while climbing

Normal Use hands freely for manipulating

One hand support for climbing

Can use hands for playing while walking or standing

2-3 yrs

Normal tone Running

Climbing stairs

More refined jumping

Symmetrical contraction & relaxation of both limbs while jumping

Limb dissociation reciprocal movmt. of limbs

Normal No support required

Use hands simultaneously for manipulation

Play-catches ball

3-4 yrs

Normal tone Stands on preferred leg, 5-10secs

Heel to toe stand

Extension of preferred leg

Flexion of leg

Dorsiflexion neutral - plantarflexion

Hyperextension in trunk

Flex./Add. Of upper limb

Normal Play

More refined counterpoising

4-5 yrs

Normal tone Balance on one leg (10sec)

Walks on narrow line

Extension and adduction of hip

Counterpoising

Normal Play

More refined counterpoising


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Weight Shift- Slowly as the child starts learning about the environment he starts weight shifting.

Saving- With further integration, the child learns to save himself (first forwards and then laterally). With experiences of unequal weight bearing the child learns to save self and slowly he develops the saving.

Hands free- As the child experiences Saving and weight shifts this helps in the development of muscle tone, strength and slowly the child learns to lift one hand, slowly progress to both hands and then to in hand manipulation. The ability to use bilateral hand movements in a coordinated way is said as hands free.

Tilt/Counter poising- Once both hands are free, there is further increase in pelvic stability with dissociation of the body in segments. This enables the child to tilt without changing the base of support when pushed suddenly. The body resists the change in COG (as in saving) by tilting.

Legs free- After tilting the child now develops dissociation of lower limbs with enables the child in transition of posture and to move in further higher postures.

Pivoting- Dissociation with increasing stability helps in rolling and pivoting.

Moving out of posture- As now the Development has completed from head to toe, the child will now move on to further higher posture.

Note= The sequence of development is same in all children and in all the postures. The child needs to complete the sequence before moving to higher posture. However this might always be not true, a child in a higher posture may also have some missing links present.


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II a. Reflexes

Reflex is a specific automatic involuntary response to a specific stimulus to the body. It is controlled by the spinal cord without the involvement of the CNS.

1. Local static reaction- These stiffens the body weight against gravity.

2. Segmental static reaction- Involves more than one body segment and includes the flexor withdrawal reflex, extensor thrust reflex and the crossed extensor reflex.

3. General static reaction (attitudinal reflexes)- These involves changes in position of the whole body in response to changes in head position. These reflexes include the ATNR,STNR and TLR

4. Righting reaction- These allow us to assume or resume a specific orientation of the body in space and in relationship to the head and ground. There are 5 types of righting reactions-

a) Optical righting reaction which contributes to the reflex orientation of the head using visual inputs.

b) Labyrinthine righting reaction which orients the head to an upright vertical position in response to vestibular signals.

c) Cubed on-head righting reaction which orients the head in response to proprioceptive and tactile signals from the body in contact with a supporting surface. Landau reaction is an example of all 3 reactions mentioned above.

d) Neck on body righting reaction orients the body in response to cervical afferents which report changes in the position of the head neck to forms of this reflex have been reported log rolling(immature form) and segmental rolling (mature form).

e) Body on body righting reaction- Keeps the body oriented with respect to the ground, regardless of the position of the head.

5. Balance and protective reaction- These emerge in association with a sequentially organised series of equilibrium reactions. These are of 3 types:-

a) Tilt reaction are used for controlling the center of gravity to a tilting surface

b) Postural fixation reaction (saving reaction) - Are used to recover from forces applied to the other parts of the body.

c) Parachute or protective responses- Protect the body from injury during a fall.


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II b. Role of reflexes in development

S.No Reflex Normal until

Stimulus Response Contribution

1. Sucking 3 mon Introduce finger into mouth

Sucking action of lips and jaw Development of oral muscles, tongue placement, swallowing and gag reflex.

2. Rooting 3 mon Touch baby cheeks Head turn towards stimulus Develops opening of mouth.Helps in localisation of breast.

3. Cardinal points

2 mon a)Touch corner of mouth

b)center of upper lip stimulated

c)Center of bottom lip is stroked.

a) Bottom lip lowers on same side and tongue moves towards point of stimulation. When fingers slide away, the head turns to follow.

b) Lip elevates, tongue moves towards place stimulated. If finger slides along oronasal groove then head extends.

c) Lip is lowered and tongue is directed to site of stimulation. If finger moves towards chin, the mandible is lowered and chin flexed.

Helps to locate nipple. Develops lateralisation of tongue.

4. Grasp 3 Mon Press finger on Ulnar side of palm

Fingers flex and grip objects (head in midline during rest)

Development of flexor tone on hand and upper extremities.

5. Hand opening

1 mon Stroke Ulnar border of palm and little finger

Automatic opening of the hand. The baby learns extension movement of finger

6. Foot grasp 9 mon Press sole of foot behind the toes

Grasping response of feet Helps baby to grasp the surface when held in standing

7. Placing Remains Bring the anterior aspect of foot or hand against the edge of table.

Child lifts limbs up to step onto table. Helps to place foot in the appropriate position for standing and locomotion. Ability to place the hand and upper extremity in a position for support in sitting and quadruped position.

8. Primary walking

2 mon Hold baby upright and tip forwards, sole of foot press against table.

Initiates reciprocal flexion and extension of legs.

It indicates the potential for automatic reciprocal walking.


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9. Galants trunk incuvation

2 mon Stroke back lateral to the spine.

Flexion of trunk towards the side of stimulus.

Initiates unilateral trunk mobility.

Creates asymmetrical pattern of movement. Initial movement for rotation initiates amphibian movement necessary for creeping, crawling breaks up symmetrical pattern of movement.

10. Automatic Sitting

2 mon Pressure id placed on the thighs and the head is held in flexion, supine position.

Child pulls to sitting from supine Weight bearing in development of standing.

11. Moro 0-6 months Baby supine and back of head is supported above table, drop head backwards, associated with loud noise.

Abduction and extension of arms. Hands open. This phase is followed by adduction of arms as if in embrace.

Develops extensor tone bilaterally in upper extremities and fingers. As this reflex matures and integrates the upper extremities are prepared for propping and parachute reaction.

12. Startle Remains Obtained by sudden loud noise or tapping the sternum

Elbow is flexed (not extended as in Moro) and hand remains closed.

Helps as protective function.

13. Landau 3 months to 2 years, strong 10 months

Child held in ventral suspension, head lift

The head,spine and legs extended. Extended arms and shoulders.

Develops extensor tone in the neck musculature of the neck to the trunk to the hips, knees, ankles and feet.

A precursor to good trunk extension for straight sitting.

Develops the balance of flexors and extensors for stable sitting, especially of the hip musculature.

14. Flexor withdrawal

2 months Supine; head mid line;legs extended- stimulates sole of foot

Uncontrolled flexion response of stimulates leg(do not confuse with response to tickling)

Helps in protective reaction.

Helps to develop between flexor and extensor tone.

15. Extensor thrust

2 months Supine; head mid position, one leg extended opposite leg flexed-turn head to

Uncontrolled extension of stimulated leg (do not confuse with response of tickling)

Helps in extensor tone in legs.


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one side

16. Crossed extension

3 months Supine, head , mid position, legs extended stimulate medial surface of one leg by tapping

Opposite leg adducts, extends, internally rotates, foot planter flexes (typically scissor position).

Develops alternative extensor tone in the lower extremities breaks up symmetrical flexion and extension movement, precursor to amphibian movement in preparation for creeping and crawling and walking pattern

17. ATNR 6 Months

Usually pathological

Baby supine, head in mid line, arms and legs extended- turn head to one side

Extension of arm and leg on face side, or increase in flexor tone.

Breaks symmetrical flexion/extension pattern of movement. Enables each side of body separately.

18. STNR Rare and usually pathological

1) Baby is quadruped position or over testers knees- ventroflex the head.

2)Position as above dorsiflex the head

Arms flex or flexor tone dominates.

An arm extendes or extensor tone dominates; legs flex or flexor tone dominates.

Helps in creating a balance between flexor and extensors for stable position against gravity.

Helps in developing prone on elbows to extended elbows to 4 foot quadruped to reciprocal crawling

19. Tonic Labyrinthine supine

Pathological Baby supine, head in mid position; arms and leg extended, test stimulus is the position.

Extensor tone predominates when the arms and legs are passively flexed

Develops extensor tone throughout body.

Creates ability to reach.

Brings limbs to mid line, cross midline.

Free limbs for function away from body, reach, spatial orientation and direction.

20. Tonic Labyrinthine prone

3 months Baby prone; head in mid position.Test stimulus- prone postion.

Unable to dorsifles head, retract shoulders, extend trunk, arms, legs.

Stimulation of flexor tone of the total body, helps to counter balance the extensor tone in supine.

This gives stability to proceed prone development.

21. Positive supporting

3 months Hold baby in standing position press down the soles of feet

Increase of extension in legs, planter flexion, genu recurvatum may occur.

Helps to develop co-contraction of flexor and extensor necessary for standing.

22. Negative supporting

3-5 months Hold in weight bearing position

Baby sinks ataxia Allows the child for voluntary weight bearing.


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23. Neck righting

5 months Supine, rotate head to one side, actively or passively

Body rotates in same direction as the head.

It initiates rolling(Log rolling)

24. Associated reaction

pathological Have baby squeeze an object(with involved side)

Clench of other hand or increase of tone in other parts of body. Abnormal overflow.


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Righting Reactions

S.No Reaction Emerges at Stimulus Response Contributions

1. Amphibian 4-6 Months Baby in prone, head in mid position, legs extended, lifts pelvis on one side.

Automotive flexion outward of hip and knee on same side.

Initiates to attain quadruped position and crawling.

2. Body righting reaction

6- 10 Months If the child rotates hip and knee (on arm on head actively)

Active segmental reaction.

Dissociation of head and limb occurs which helps in crawling, walking etc.

3. Body righting derotative

4 -6 Months Baby in supine rotate head( on one side) Knee on one side

Active derotation at waist is segmental rotation of trunk between shoulders and pelvis.

1) Segmental contraction f trunk, neck, hip & leg muscles.

2) Dissociation of trunk and limb helps in crawling and later walking.

4. Labyrinthine head righting vestibular righting

2-6

Months

1) Hold the baby blindfolded in prone in supine, as head drops.

2) Hold the baby blindfolded in supine, in space, as head drops.

3) Hold the baby blindfolded, hold around pelvis and tilt it to one side.

Head raises to normal position, face vertical mouth horizontal.

Head raises to normal position, face vertical mouth horizontal.

Head rights itself to normal position, face vertical mouth horizontal.

These reactions help to attain antigravity position.

5. Optical righting 6 Months Hold baby either in supine (or in prone, in space as head drops)

Head raises t normal position face vertical mouth horizontal.

Helps to attain antigravity posture.


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Equilibrium Reaction

S.No Reaction Emerges at Stimulus Response Contribute

1. Tilt Reactions

Supine and Prone

6 Months Baby on tilt board, arms and legs extended, tilt the board on one side.

Lateral curving of head and thorax, parachute reaction in limbs accompany trunk rotation.

All the equilibrium reactions are protective. They facilitate the body to maintain various body postures external force and balance in dynamic postures.

2. Four point kneeling 7-12 months Child in Quadruped position

a) Tilt towards one side.

b) Tilt forwards.

c)Tilt backwards

a) Lateral curving of head and thorax.

Abduction extension of arms and legs on raised side and protective reactions on lowered side may accompany this.

b) Forward head and back flexed. Backward-head and back extended.

Do-

3. Sitting 9-12 months Baby seated n chair

a)Tilt the child to one side

b) Tilt the child forward.

c) Tilt the child backward.

a)

Head and thorax curve, abduction-extension of arms and legs on raised side and protective reactions on lowered side may accompany this.

Child extends head and back.

Child flexes head and back.

Do-

4. Kneel standing 18 months Child in kneel sitting position.

Tilt to one side

Head and thorax curve, abduction- extension of arm and leg on raised side, other protective reaction may accompany this.

Do-

5. Standing 12-18 months

Child in standing position

a)Tilt sideways

a) Head and thorax curve abduction extension of arms and leg on raised side, other protective reactions may accompany this.

b)Tilt forwards

c) Tilt Backwards

Do-


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II c. Contribution of Reflexes

1. Gallants Trunk Incurvation Stimulus: Stroke back, lateral to the spine. Response: Flexion of trunk towards side of trunk

Contribution:

Initiates unilateral trunk mobility. Creates asymmetrical pattern of movement. Initial movement for rotation. Initiates amphibian movement necessary for creeping, crawling.

2. Cross Extension Reflex Stimulus: Head mid-position, legs extended, stimulate medial surface of one leg by tapping Response: Opposite leg adducts, extends, internally rotates and foot plantar flexes Contribution:

Develops alternating extensor tone in the lower extremities Breaks up symmetrical flexion and extension movements Precursor to amphibian movement in preparation for creeping, crawling and walking

patterns

Enables crossing midline Combines with the positive supporting reflex in the early stages to supply sufficient extensor

tone to stand on one lower limb while the opposite limb flexes

3. Cross Tonic Labyrinthine Reflex Stimulus: Head mid-position, stimulus is the prone position Response: Unable to dorsiflex head, retracts shoulders, extends trunk, arms and legs Contribution:

Stimulation of flexor tone of total body Counterbalance extensor tone developing in supine position Balance is maintained; this gives the stability that is necessary for prone development to

proceed to higher levels

4. Symmetrical Tonic Neck Reflex (STNR) Stimulus: Quadruped position, ventroflex the head Response: Arms flex (increase in flexor tone) & legs extend (increase in extensor tone) Contribution:

Helps in creating a balance between flexors and extensors for stable position against gravity Helps in developing prone-on-elbows to extended elbows to 4 foot quadruped to reciprocal

crawling

5. Landau Reaction


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Stimulus: Child head in ventral suspension, lift head; depress head Response: Head, spine and legs extend, extend arms at shoulder; Hip, knees and elbows flex Contribution:

Develops extensor tone in the neck musculature of the neck, to the trunk to the hips, knees, ankles and feet

A precursor to good trunk extension for straight sitting Develops the balance of flexors and extensors for stable sitting, especially of the hip

musculature

6. Righting Reaction (Amphibian) Stimulus: Head mid-position, legs extended, lift pelvis on one side Response: Automatic flexion outward of hip and knee on same side Contribution:

With other reflexes act as a precursor to creeping

7. Tilt Reaction (Prone) Stimulus: Lying in prone position on the tilt board, arms and legs extended, tilt board to one side Response: Lateral curving to head and thorax, protective reaction in limbs accompany trunk reaction Contribution:

Enables movement of trunk to maintain balance

8. Four-point kneeling Stimulus: Quadruped position, tilt board towards one side; tilt forward and backward Response: Lateral curving of head and thorax, abduction-extension of arm and leg on raised side, protective reaction on lower side; Forward head and back flex, Backward head and back extend Contribution:

Maintain balance and equilibrium

9. Placing

Stimulus: Infant held up; dorsum of hand/foot brushed against edge of table Response: Lifts (flexes) hand/foot and places it on the table/surface Contribution:

Ability to place the foot in appropriate position for standing and locomotion Initiates flexion/extension pattern for walking

10. Saving Stimulus: Sudden tip sideways/backwards Response: Hands extend for balance / counterpoising Contribution:

Development of trunk muscle tone Helps in attaining postural fixation (head on trunk & trunk on pelvis) and lateral

sideways control

11. Positive/Negative Support (Upright posture) Stimulus: Weight bearing


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Response: Plantar flexion, hyperextension at knee and extension at hip (pillar like lower limb Positive) Sudden sinking (Negative) Contribution:

Precursor to standing and walking through the development of extensor tone in the lower extremities and to a lesser degree in hips and trunk

12. Automatic walking (Upright posture) Stimulus: Stimulate sole of feet Response: Walking pattern, scissoring walk Contribution:

Indicates potential for automatic, reciprocal walking Develops flexor & extensor tone balance for future standing & walking Dorsiflexion of foot and extension on toes

References: Sheridan, Mary D., From birth to five years, Published in 1997 by Routledge Gassier, A guide to the phycho-motor development of the child, Fiorentino, Mary R., A basis for sensorimotor development Normal and Abnormal, Published by Charles C. Thomas Levitt, Sophie, Treatment of Cerebral Palsy and Motor Delay, 3rd Edition, Published in 2000 by Blackwell Science Ltd.


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II d. GRASP Grasp is defined as the attainment of an object by hand. It is an important milestone by which the child starts using its hands. Contribution of reflexes in development of grasp: 1) Palmer grasp reflex (Birth to 3 months)

Stimulus- tactile stimulus to the palmer side of hand. Response- Mass finger flexion with adduction of the thumb. (formation of fist) Contribution- It helps in the development of sustained holding.

2) Avoidance reaction (From neonatal period to 12 months) Stimulus- Tactile stimulation of the dorsal aspect of the hand and fingers, ulnar

border of hand and palmer surface of the fingers. Response- Withdrawal of the hand and palmer surface of the fingers. Contribution- Initiates releasing of objects.

3) Traction reflex (from birth to 5 months) Stimulus- Passive abduction of shoulder. Response- Flexion pattern throughout the upper limb. Contribution-It helps in development of brief holding.

4) Imitative grasp reaction- Stimulus- Tactile stimulation of either radial or ulnar side of hand. Response- Supination at wrist. Contribution- Helps in developing proper positioning of hand to grasp a desired

object.


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Development of Grasp: S. no Month Type of Grasp Pattern 1. At birth Thumb is adducted in the palm and fingers are flexed. 2. Up to 1 month On stroking ulnar side of palm and little finger the

hand opens reflexively. 3. 2 months Thumbs are adducted 4. 0-3 months Grasp reflex- Reflexively fingers are flexed. 5. 3 months Traction response and grasp reflex absent. 6. 3-4 months Ulnar palmar grasp- Child holds the object with little

and ring finger against the palm without the use f thumb.

7. 4-5 months Palmer grasp- Grasps the objects against the palm without the use of thumb. (Primitive Squeeze)

8. 5-6 months Radial Palmer grasp- Holds the object with his thumb, index and middle finger against the palm.

9. 6-8 months Raking grasp- The child can pick up small beads by flexing the fingers towards the palm without using the thumb. Can transfer from one hand to another(7 Months onwards)

10. 8 months Superior palmer grasp- Grasps an object with finger and base of thumb( Initial stage of thumb opposition)

11. 9 months Radial digital grasp- Grasps the object with the thumb index and middle fingers without using the palm.

12. 10 months Inferior Pincer(Pre- Pincer) Grasp- grasps an object with his thumb and index finger; Extend finger- The child extends the wrist while grasping in order to facilitate the function of finger flexors.

13. 11-12 months Superior Neat Pincer grasp- Can preciously grasps a tiny object with thumb and index finger opposition.

14. 12-18 months Pronated and Supinated grasp- Can hold a cylindrical object ( Marker pen) in the palm with flexion of the fingers and thumb.

15. 3-4 years Tripod Grasp- Can hold a pencil precisely between the tips of index, middle finger and thumb (By opposition between thumb and the fingers).


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III. High Risk Infants: The term high-risk infants refer to those infants whose peri-natal medical course might contribute to motor, cognitive or social deficits. Risk factors are defined as the characteristics or circumstances of a person or group that are associated with increased risk of having, developing or being specially adversely affected by a morbid process. Risk factors may have a single effect or a combination of effects for particular outcomes. Tjossems categories of Biological, Established and Social risk provide a framework for categorizing indicators for neonatal therapy referral.

Biological Risk: It refers to neurodevelopmental risk due to medical or physiological conditions in the prenatal, perinatal or neonatal period. Biological risks include placental abnormalities, labour/ delivery complications, prenatal infection, and teratogenic factors.

Biological Risk:

Birth weight of 1500 g or less. Gestational age of 32 weeks or less. Small for gestational age (less than 10th percentile for weight). Prenatal exposure to drugs or alcohol. Ventilator requirement for 36 hours or more. Intracranial haemorrhage: grade III. Periventricular leukomalacia. Muscle tone abnormalities (hypotonia, hypertonia, asymmetry of tone/ movement). Recurrent neonatal seizures (3 or more). Feeding dysfunction. Symptomatic TORCH infections (Toxoplasmosis, Rubella, Cytomegalovirus infection, Herpes

virus type II infection. Meningitis. Asphyxia with Apgar score less than 4 at 5 minutes. Multiple birth

Established Risk: Established risk is the risk for neurodevelopmental deficits associated with a diagnosis that is clearly established in the neonatal period.

Hydrocephalus Microcephaly Chromosomal abnormalities Musculoskeletal abnormalities (congenital dislocated hips, limb deficiencies, arthrogryposis) Brachial plexus injuries (Erbs palsy, Klumpkes paralysis)

Environmental/ Social Risk: It involves developmental risk related to competency in parenting roles and factors in family dynamics. Such risks may be heightened by prolonged


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hospitalization of infants with sub optimal levels of stimulation and interaction in the intensive care nursery environment, inadequate infant- parent attachment.

Behavioral state abnormalities (lethargy, excessive irritability, behavioral state liability).


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Levels of risk

III Severe

Severe respiratory distress requiring mechanical ventilation Intracranial hemorrhage Gestational age between 26 to 30 weeks Small for gestational age, with a birth weight of less than 1750 grams Persistent atypical patterns of neurological behavior Congenital infections

II Moderate

Birth weight of less than 1750 grams Hyperbilirubinemia Congenital heart disease Respiratory distress without mechanical ventilation Post- maturity

I Mild

Birth weight of 1750-2500 grams


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II. Paediatric Neurological Assessment

Assessment

Child developmental assessment needs an understanding of various areas of child development like- Gross and fine motor, Social emotional, speech and language, cognitive development, vision and hearing. All assessment procedures should focus:-

S- Subjective

O- Objective

A- Assessment

P-Procedure

While we reach towards Short Term Goals we need to do repeated reassessments to monitor the childs progress.

Initial Detailed assessment- Setting goal and activities- Working on goals- Re assessment- New goal making or working on goals assessment

This is a continuous phase of the assessment procedure as mentioned above. While assessing the child we need to know that we might not be able to complete all the assessments in a single day, the complete childs assessment could take few days, in these cases often we have to rely on the information from the parents as they are considered a reliable resource.

At times parents have difficulty in understanding the outcomes of the therapy program. In these cases an initial assessment video should be taken and after 2-3 months we can take another video. This would help therapists to provide a strong support for their interventions and the resultant outcome.

Observation Observation begins before making any physical contact and from enough of a distance to encompass the infant as a whole.

Behavioral indicators of stress and stability

Signs of stability or approach signals Smooth respiration Pink, stable color Animated facial expression Brightening of the eyes Cooing Smiling Hand to mouth activity Well-regulated muscle tone Smooth body movements, minimal movement


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Signs of Stress Physiological Indicators:

Color changes Cyanosis Change in respiratory rate and rhythm Change in heart rate Coughing Sneezing Yawning Vomiting Hiccup

Motor Indicators:

Sudden change in muscle tone Flaccidity (truncal, extremities, facial) Stiffness

1. Ophisthotonos 2. Finger splaying

Alterations in the quality of movement Disorganized movement Jitteriness

Behavioural Indicators: Irritability (crying, inconsolability) Staring Gaze aversion Hyper alertness Sleeplessness and restlessness

ANTHROPOMETRIC MEASUREMENTS The head and chest circumference and the length of the infant are measured and recorded.

Head circumference:

Head circumference is a useful measure of intracranial volume and helps in assessment of brain development by measuring the growth of the brain.

Head circumference is measured at the maximum skull circumference. Measure should be taken using a flexible tape. Tape should be moved around, to ensure that this is the largest circumference for the particular infant being measured.


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Measure the occipito-frontal head circumference, at its maximum and ensure that it falls within the normal range (31-38 cm at term).

The brain grows to 80% of its adult volume during the first 2 years of life so many neurological diseases that occur early in life will impact the growth of the brain.

A small head (Microcephaly) or a large head (Macrocephaly or Hydrocephalus) can be key findings in explaining the neurological abnormalities of a child.

Weight: A standing scale can be used by having an adult hold the infant and weighing the infant and adult together. The adult is then weighed alone and the adults weight is subtracted from the total. Weight should be measured again to ensure accuracy. If the two weights differ, a third weight should be taken and so on until two results agree.

During the first 3 days after birth, infants normally lose upto 10 to 15 percent of their body weight

Length: With infants under age 2 years, recumbent length is measured as a substitute for height.

The recommended procedure is to use a measuring table with movable perpendicular head and footboards and two persons to help hold the infant. One person places the supine infants head against the headboard. The other person straightens the infants hips and knees, places the footboard against the sole of infants foot and read the length measure.

A second alternative method is to stretch a tape measure beside or under the properly positioned infant and read the length directly from the tape.

PALPATION:

Feel the anterior fontanelle for its tension. Fullness may indicate raised intracranial pressure (cerebral edema, hydrocephalus or meningitis). The posterior fontanelle is also often open at this age.

Inspection of the inside of the mouth is best done either while the baby is crying or by making him open it. One should ensure that the palate is intact.


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III. Rehabilitation

To restore to useful life, as through therapy and education or to restore to good condition, operation, or capacity is called Rehabilitation.

WHO states the rehabilitation of persons with disability as:-

Rehabilitation of people with disabilities is a process aimed at enabling them to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels. Rehabilitation provides disabled people with the tools they need to attain independence and self-determination.

Professionals involved in Rehabilitation are:-

1. Physicians, Surgeons, Doctors

2. PT, OT, SLT, PRO

3. Special Educators, Nurses, Dietician, Counsellor, Psychologist, Dance and drama therapists, art therapist

4. Para professionals

5. Lawyers and policy makers

Broadly classifying the professionals into 3 sectors

1. Medical Rehabilitation (Doctors and therapists) 2. Educational or adaptive life rehab (Teachers and skills training professionals) 3. Social rehabilitation (By policy makers and para-professionals)

Child Rehabilitation

Medical Rehabilitation

Adaptive living/ educational Rehabilitation

Social

Rehabilitation


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Need to understand Rehabilitation

1. The Status of children with disabilities

Around 10% of the world's population, or 650 million people, live with a disability. They are the world's largest minority.

20% of the world's poorest people are disabled, and tend to be regarded in their own communities as the most disadvantaged.

80% of persons with disabilities live in developing countries Between 120 and 150 million disabled children and young people live in the world. Less than 10 % of these children attend school. The global literacy rate for adults with disabilities is as low as 3 % and 1% for

women with disabilities. 30% of street youths are disabled. Violence against children with disabilities occurs at annual rates at least 1.7 times

greater than for their non-disabled peers. For every child killed during armed conflicts, three are injured and permanently

disabled. Comparative studies on disability legislation shows that only 45 countries have anti-

discrimination and other disability-specific acts.

Sources: UNICEF, UNDP, World Bank, CRIN.

Indian scenario on Disability

The Indian Census 2001 reports that 21.9 million persons in the Indian total population (2.13%) are disabled, and that 1.67% of the total population within the age-group 0-19 years (7 million) are living with disability. This data includes persons with visual, hearing, speech, physical and mental impairments. The data from studies by WHO and other international health organizations indicates much higher numbers, more towards 5-6 %.

Of all persons with disability, 35.9% are in the 0-19 age-group. One in every 10 children is born with, or acquires, a physical, mental or sensory disability. 75% of the disabilities are preventable. Only 1% of children with disability have access to education. Hardly 50% of disabled children reach adulthood, and no more than 20% survive to cross the

fourth decade of life.

With this much of burden on the health care system and more number of children adding up every day, we do not have so many rehabilitation professionals to provide Rehabilitation to the children and persons with disability in India.

IV. ICF (International Classification of Functioning, disability and health)

The International Classification of Functioning, Disability and Health, known more commonly as ICF, is a classification of health and health-related domains. These domains are classified from body,


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individual and societal perspectives by means of two lists: a list of body functions and structure, and a list of domains of activity and participation. Since an individuals functioning and disability occurs in a context, the ICF also includes a list of environmental factors.

The ICF is WHO's framework for measuring health and disability at both individual and population levels. The ICF was officially endorsed by all 191 WHO Member States in the Fifty-fourth World Health Assembly on 22 May 2001(resolution WHA 54.21). Unlike its predecessor, which was endorsed for field trail purposes only, the ICF was endorsed for use in Member States as the international standard to describe and measure health and disability.

The ICF puts the notions of health and disability in a new light. It acknowledges that every human being can experience a decrement in health and thereby experience some degree of disability. Disability is not something that only happens to a minority of humanity. The ICF thus mainstreams the experience of disability and recognises it as a universal human experience. By shifting the focus from cause to impact it places all health conditions on an equal footing allowing them to be compared using a common metric the ruler of health and disability. Furthermore ICF takes into account the social aspects of disability and does not see disability only as a 'medical' or 'biological' dysfunction. By including Contextual Factors, in which environmental factors are listed ICF allows to records the impact of the environment on the person's functioning.

Source- http://www.who.int/classifications/icf/en/


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V. Goal Making in Early Intervention Therapy

Goal making in therapy is a more crucial part then planning the therapy sessions, as it is not one persons view about the goal, but we should also know about the parents opinion on goal making as if what in their view is important.

A child's earliest years are filled with new stimulations and novel experiences that drive his or her cognitive, social, and physical growth. The first 3 years of life are a critical time for brain development, especially if a child is delayed or restricted in development. If a child needs support to develop optimally, rehabilitation therapy can help.

Early intervention is a collection of therapy and support services provided to children from birth to 3 years old who have disabilities, or who are at risk for developing them. Early Intervention provides the help they need to succeed later in life.

The goals of early intervention should be SMART:-

S- Subjective/specific

M- Measureable

A- Achievable

R- Realistic

T- Time frame

The goals made in Paediatric Rehabilitation are of 2 types:-

1. Long term Goal (LTG) (6Mo-1year)- It is usually advisable to make goals like a higher level posture. In case this is not possible to attain a higher posture, our goal should be to maintain the posture and work on any other related issues like (fine motor, cognitive, sensory etc.) and prevent regression.

2. Short Term Goal (STG) (3-6month) - These goals help us to reach our Long term goal and keep track of the progress of child towards the same.

Further to reach to the short term and long term goals we need to find out the activities or therapies which would help us in reaching our target. These developmental activities help to facilitate the growth and development of the child and focus on the home program that the parents can do at home.

Example: For achieving a Short Term Goal of bilateral midline hand movements of a child the activities could be:-

1. Playing with a ball 2. Playing clap clap 3. Asking the child to bring a Doll or toy that is fairly big enough that the child needs both hands

to hold the object 4. Providing opportunities to the child to use his reasoning as how will he utilise his abilities to

use both hands


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5. Finally the parents need to teach on the importance of mid line orientation as to how it is helping us in daily life and how would the child be benefited in near future.

For children with developmental delays or a known physical or mental condition associated with a high probability of delays, therapy can help improve their motor, cognitive and sensory processing along with communication, and play skills. The goal is to enhance development, minimize the potential for developmental delay, and help families to meet the special needs of their infants and toddlers.

Based on the family's values and priorities, it outlines what parents want their child to learn to do. Next, the coordinator and parents determine what kind of expertise might be most useful to achieve the outcomes. Therapy may be the only service or one of several services identified through the IFSP (Individual Functional Screening Profile) process as best able to help the child reach his or her goals.

Paediatric therapy services should be tailored to the childs family, including siblings and other family members, and services should be altered and adapted as the familys needs change.


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VI. Sensory Processing Disorder Checklist: Signs and Symptoms Of Dysfunction

The purpose of this sensory processing disorder checklist is to help parents and professionals who interact with children become educated about particular signs of sensory processing dysfunction.

Disclaimer: This checklist is not to be used as the absolute diagnostic criteria for labelling children with sensory processing disorder.

Please understand the "Five Caveats" that Carol Stock Kranowitz points out in her book, "The Out-Of-Sync Child" (1995), about using a checklist such as this. She writes: 1. "The child with sensory dysfunction does not necessarily exhibit every characteristic. Thus, the child with vestibular dysfunction may have poor balance but good muscle tone."

2. "Sometimes the child will show characteristics of a dysfunction one day but not the next. For instance, the child with proprioceptive problems may trip over every bump in the pavement on Friday yet score every soccer goal on Saturday. Inconsistency is a hallmark of every neurological dysfunction. " 3. "The child may exhibit characteristics of a particular dysfunction yet not have that dysfunction. For example, the child who typically withdraws from being touched may seem to be hypersensitive to tactile stimulation but may, instead, have an emotional problem." 4. "The child may be both hypersensitive and hyposensitive. For instance, the child may be extremely sensitive to light touch, jerking away from a soft pat on the shoulder, while being rather indifferent to the deep pain of an inoculation." 5. "Everyone has some sensory integration problems now and then, because no one is well regulated all the time. All kinds of stimuli can temporarily disrupt normal functioning of the brain, either by overloading it with, or by depriving it of, sensory stimulation."


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Tactile Sense: input from the skin receptors about touch, pressure, temperature, pain, and movement of the hairs on the skin.

Signs of Tactile Dysfunction

1. Hypersensitivity to Touch (Tactile Defensiveness)

__ becomes fearful, anxious or aggressive with light or unexpected touch __ as an infant, did/does not like to be held or cuddled; may arch back, cry, and pull away __ distressed when diaper is being, or needs to be, changed __ appears fearful of, or avoids standing in close proximity to other people or peers (especially in lines) __ becomes frightened when touched from behind or by someone/something they can not see (such as under a blanket) __ complains about having hair brushed; may be very picky about using a particular brush __ bothered by rough bed sheets (i.e., if old and "bumpy") __ avoids group situations for fear of the unexpected touch __ resists friendly or affectionate touch from anyone besides parents or siblings (and sometimes them too!) __ dislikes kisses, will "wipe off" place where kissed __ prefers hugs __ a raindrop, water from the shower, or wind blowing on the skin may feel like torture and produce adverse and avoidance reactions __ may overreact to minor cuts, scrapes, and or bug bites __ avoids touching certain textures of material (blankets, rugs, stuffed animals) __ refuses to wear new or stiff clothes, clothes with rough textures, turtlenecks, jeans, hats, or belts, etc. __ avoids using hands for play __ avoids/dislikes/aversive to "messy play", i.e., sand, mud, water, glue, glitter, play dough, slime, shaving cream/funny foam etc. __ will be distressed by dirty hands and want to wipe or wash them frequently __ excessively ticklish


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__ distressed by seams in socks and may refuse to wear them __ distressed by clothes rubbing on skin; may want to wear shorts and short sleeves year round, toddlers may prefer to be naked and pull diapers and clothes off constantly __ or, may want to wear long sleeve shirts and long pants year round to avoid having skin exposed __ distressed about having face washed __ distressed about having hair, toenails, or fingernails cut __ resists brushing teeth and is extremely fearful of the dentist __ is a picky eater, only eating certain tastes and textures; mixed textures tend to be avoided as well as hot or cold foods; resists trying new foods __ may refuse to walk barefoot on grass or sand __ may walk on toes only

2. Hyposensitivity To Touch (Under-Responsive):

__ may crave touch, needs to touch everything and everyone __ is not aware of being touched/bumped unless done with extreme force or intensity __ is not bothered by injuries, like cuts and bruises, and shows no distress with shots (may even say they love getting shots!) __ may not be aware that hands or face are dirty or feel his/her nose running __ may be self-abusive; pinching, biting, or banging his own head __ mouths objects excessively __ frequently hurts other children or pets while playing __ repeatedly touches surfaces or objects that are soothing (i.e., blanket) __ seeks out surfaces and textures that provide strong tactile feedback __ thoroughly enjoys and seeks out messy play __ craves vibrating or strong sensory input __ has a preference and craving for excessively spicy, sweet, sour, or salty foods

3. Poor Tactile Perception And Discrimination:


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__ has difficulty with fine motor tasks such as buttoning, zipping, and fastening clothes __ may not be able to identify which part of their body was touched if they were not looking __ may be afraid of the dark __ may be a messy dresser; looks disheveled, does not notice pants are twisted, shirt is half un tucked, shoes are untied, one pant leg is up and one is down, etc. __ has difficulty using scissors, crayons, or silverware __ continues to mouth objects to explore them even after age two __ has difficulty figuring out physical characteristics of objects; shape, size, texture, temperature, weight, etc. __ may not be able to identify objects by feel, uses vision to help; such as, reaching into backpack or desk to retrieve an item


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Vestibular Sense: input from the inner ear about equilibrium, gravitational changes, movement experiences, and position in space.

Signs of Vestibular Dysfunction

1. Hypersensitivity to Movement (Over-Responsive):

__ avoids/dislikes playground equipment; i.e., swings, ladders, slides, or merry-go-rounds __ prefers sedentary tasks, moves slowly and cautiously, avoids taking risks, and may appear "wimpy" __ avoids/dislikes elevators and escalators; may prefer sitting while they are on them or, actually get motion sickness from them __ may physically cling to an adult they trust __ may appear terrified of falling even when there is no real risk of it __ afraid of heights, even the height of a curb or step __ fearful of feet leaving the ground __ fearful of going up or down stairs or walking on uneven surfaces __ afraid of being tipped upside down, sideways or backwards; will strongly resist getting hair washed over the sink __ startles if someone else moves them; i.e., pushing his/her chair closer to the table __ as an infant, may never have liked baby swings or jumpers __ may be fearful of, and have difficulty riding a bike, jumping, hopping, or balancing on one foot (especially if eyes are closed) __ may have disliked being placed on stomach as an infant __ loses balance easily and may appear clumsy __ fearful of activities which require good balance __ avoids rapid or rotating movements

2. Hyposensitivity to Movement (Under-Responsive):


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__ in constant motion, can't seem to sit still __ craves fast, spinning, and/or intense movement experiences __ loves being tossed in the air __ could spin for hours and never appear to be dizzy __ loves the fast, intense, and/or scary rides at amusement parks __ always jumping on furniture, trampolines, spinning in a swivel chair, or getting into upside down positions __ loves to swing as high as possible and for long periods of time __ is a "thrill-seeker"; dangerous at times __ always running, jumping, hopping etc. instead of walking __ rocks body, shakes leg, or head while sitting __ likes sudden or quick movements, such as, going over a big bump in the car or on a bike

3. Poor Muscle Tone And/Or Coordination:

__ has a limp, "floppy" body __ frequently slumps, lies down, and/or leans head on hand or arm while working at his/her desk __ difficulty simultaneously lifting head, arms, and legs off the floor while lying on stomach ("superman" position) __ often sits in a "W sit" position on the floor to stabilize body __ fatigues easily! __ compensates for "looseness" by grasping objects tightly __ difficulty turning doorknobs, handles, opening and closing items __ difficulty catching him/her self if falling __ difficulty getting dressed and doing fasteners, zippers, and buttons __ may have never crawled as an baby __ has poor body awareness; bumps into things, knocks things over, trips, and/or appears clumsy __ poor gross motor skills; jumping, catching a ball, jumping jacks, climbing a ladder etc.


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__ poor fine motor skills; difficulty using "tools", such as pencils, silverware, combs, scissors etc. __ may appear ambidextrous, frequently switching hands for coloring, cutting, writing etc.; does not have an established hand preference/dominance by 4 or 5 years old __ has difficulty licking an ice cream cone __ seems to be unsure about how to move body during movement, for example, stepping over something __ difficulty learning exercise or dance steps


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Proprioceptive Sense: input from the muscles and joints about body position, weight, pressure, stretch, movement, and changes in position in space.

Signs Of Proprioceptive Dysfunction

1. Sensory Seeking Behaviors:

__ seeks out jumping, bumping, and crashing activities __ stomps feet when walking __ kicks his/her feet on floor or chair while sitting at desk/table __ bites or sucks on fingers and/or frequently cracks his/her knuckles __ loves to be tightly wrapped in many or weighted blankets, especially at bedtime __ prefers clothes (and belts, hoods, shoelaces) to be as tight as possible __ loves/seeks out "squishing" activities __ enjoys bear hugs __ excessive banging on/with toys and objects __ loves "roughhousing" and tackling/wrestling games __ frequently falls on floor intentionally __ would jump on a trampoline for hours on end __ grinds his/her teeth throughout the day __ loves pushing/pulling/dragging objects __ loves jumping off furniture or from high places __ frequently hits, bumps or pushes other children __ chews on pens, straws, shirt sleeves etc.

2. Difficulty with "Grading Of Movement":

__ misjudges how much to flex and extend muscles during tasks/activities (i.e., putting arms into sleeves or climbing) __ difficulty regulating pressure when writing/drawing; may be too light to see or so hard the tip of writing utensil breaks


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__ written work is messy and he/she often rips the paper when erasing __ always seems to be breaking objects and toys __ misjudges the weight of an object, such as a glass of juice, picking it up with too much force sending it flying or spilling, or with too little force and complaining about objects being too heavy __ may not understand the idea of "heavy" or "light"; would not be able to hold two objects and tell you which weighs more __ seems to do everything with too much force; i.e., walking, slamming doors, pressing things too hard, slamming objects down __ plays with animals with too much force, often hurting them


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Signs of Auditory Dysfunction: (no diagnosed hearing problem)

1. Hypersensitivity To Sounds (Auditory Defensiveness):

__ distracted by sounds not normally noticed by others; i.e., humming of lights or refrigerators, fans, heaters, or clocks ticking

__ fearful of the sound of a flushing toilet (especially in public bathrooms), vacuum, hairdryer, squeaky shoes, or a dog barking

__ started with or distracted by loud or unexpected sounds

__ bothered/distracted by background environmental sounds; i.e., lawn mowing or outside construction

__ frequently asks people to be quiet; i.e., stop making noise, talking, or singing

__ runs away, cries, and/or covers ears with loud or unexpected sounds

__ may refuse to go to movie theaters, parades, skating rinks, musical concerts etc.

__ may decide whether they like certain people by the sound of their voice

2. Hyposensitivity to Sounds (Under-Registers):

__ often does not respond to verbal cues or to name being called

__ appears to "make noise for noise's sake"

__ loves excessively loud music or TV

__ seems to have difficulty understanding or remembering what was said

__ appears oblivious to certain sounds

__ appears confused about where a sound is coming from

__ talks self through a task, often out loud

__ had little or no vocalizing or babbling as an infant

__ needs directions repeated often, or will say, "What?" frequently


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Oral Dysfunction

1. Hypersensitivity to Oral Input (Oral Defensiveness):

__ picky eater, often with extreme food preferences; i.e., limited repertoire of foods, picky about brands, resistive to trying new foods or restaurants, and may not eat at other people's houses)

__ may only eat "soft" or pureed foods past 24 months of age

__ may gag with textured foods

__ has difficulty with sucking, chewing, and swallowing; may choke or have a fear of choking

__ resists/refuses/extremely fearful of going to the dentist or having dental work done

__ may only eat hot or cold foods

__ refuses to lick envelopes, stamps, or stickers because of their taste

__ dislikes or complains about toothpaste and mouthwash

__ avoids seasoned, spicy, sweet, sour or salty foods; prefers bland foods

2. Hyposensitivity To Oral Input (Under-Registers)

__ may lick, taste, or chew on inedible objects

__ prefers foods with intense flavor; i.e., excessively spicy, sweet, sour, or salty

__ excessive drooling past the teething stage

__ frequently chews on hair, shirt, or fingers

__ constantly putting objects in mouth past the toddler years

__ acts as if all foods taste the same

__ can never get enough condiments or seasonings on his/her food

__ loves vibrating toothbrushes and

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