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PEDIATRIC PHYSICAL THERAPY
SMC-UOS
ABNORMAL DEVELOPMENT
DR. FARJAD AFZAL
PHYSIOTHERAPIST
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Principles of development
• A continuous process from conception to maturity
• Depends on maturation and myelination of nervous
system
• The sequence is the same, the rate varies from child to
child
• Primitive reflexes should be lost before the voluntary
movement develops
• Cephalo – caudal direction of development
• Generalized mass activity→ individual responses
• No child is mentally retarded if backward in a single
field of development and normal in all others
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Introduction:
• An estimated 12-16% of children have a
developmental and/or behavior disorder
• Only 30% are identified before school
entrance
• Those detected after school entrance miss out
on early intervention services proven to have
long term health benefits
• Delay - implies slow acquisition of all skills
(global delay) or of one particular field or area
of skill (specific delay), particularly in relation
to developmental problems in the 0-5 years
age group.
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Development delay
• the condition where a child does not reach
one of the stages of development at the
expected For example, if the normal range for
learning to walk is between 9 and 15 months,
and a 20-month-old child has still not begun
walking, this would be considered a
developmental delay.
Age for walking for typically
developing children
100
90
80
70
60
50 % Walking and
40 age in months
30
20
10
0
11 12 13 15 18
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‘Normal’
Median age for walking is
12 months
Limit age (2 standard
deviations above
average) is 18 months
Types of delay
• 1.Global developmental delay implies delay in
acquisition of all skill fields (gross motor,
vision and fine motor, hearing and
speech/language, social/emotional and
behaviour). It usually becomes apparent in
thefirst 2 years of life.
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• 2.Specific developmental delay is when one
field of development or skill area is more
delayed than others or is developing in a
disordered way
Four Domains of Development
1. Gross motor skills
2. Fine motor and visual skills
3. Hearing, speech and language skills
4. Social, emotional and behavioural skills
Cognitive development refers to higher mental
function
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Abnormal motor development
This may present as delay in acquisition of
motor milestones, e.g. head control, rolling,
sitting, standing, walking or as problems with
balance, an abnormal gait, asymmetry of hand
use, involuntary movements or rarely loss of
motor skills.
Causes of abnormal motor
development include:
• cerebral palsy
• congenital myopathy/primary muscle disease
• spinal cord lesions, e.g. spina bifida
• global developmental delay as in many
syndromes or of unidentified cause
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INTRODUCTION
abnormal development
• Postural reflexes play dominant role---muscle
tone
• Muscle tone---posture and movements
• Normal reflexes---normal development
• Abnormal reflexes---abnormal tone and
posture---abnormal development
• Resulting abnormal sensorimotor
development
Spastics
• Spastics in general lack movements
• Dominated by tonic patterns
• Too much stability & abnormal reciprocal innervations
• Fixed positions
• Tends to be fixed in progravity patterns
• Lack normal antigravity patterns
• Abnormal distribution of muscle tone
• Retention of pathological tonic movements
• Male development of righting and equilibrium reactions
• Abnormal rotation patterns
• Voluntary movement slow and limited in range
• Strong tonic labyrinthine reflex
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Example-spastics
Prone to supine
• Retraction of shoulder and
neck
• Extension at hip knee and
ankle
• Inward rotation and
adduction of LL
• Inversion of feet
ATHETOID
• Athetoid in general has too much uncontrolled mobility
• Movement lack proximal stability
• Postural tone fluctuates
• Control of movements during transitional stages is
lacking
• Too much reciprocal inhibition
• Primitive reflexes are retained but not fix
• Righting reaction may be present but they manifest
unpredictable movements
• Use distal stability and trunk
• Use head to control the posture
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Athetoid- example
• Hypo tonicity
• Little tone to
control stability
• Hyper
extensibility
• Excessive
extension with
no
counterbalance
to extension
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PEDIATRIC PHYSICAL THERAPY
SMC-UOS
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Red flags & abnormal development
Red flags (1) – newborn
• State of arousal
– Lack of alertness
– Poor quality of sleep
• Abnormal cry
• Feeding problems, drooling
• Spontaneous motility (abnormal movements
– Tremor & seizures
• Abnormal tone
• Abnormal head size or shape
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Approach to a child with
27 neurodevelopmental disability
2004
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32
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Head size:
It is easy to remember the following average
figure.
• 35 cm at birth
• 47 cm (another 12 cm) at 12 months
• 49 cm (another 2 cm) at 2 years
• 50 cm at 3 year
• 52 cm at 6 years
• 53 cm at 10 years
• 56 cm as adult
Red flags (2)
Infancy/ early childhood
• Increased or reduced head circumference
• Lack of alertness, delayed social smile
• Poor head control (at 3-4 months)
• Persistent primitive reflexes (ATNR)
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35
36
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Approach to a child with
37 neurodevelopmental disability
2004
Red flags (3)
Infancy/ early childhood
• Early asymmetry (handedness <12 months)
• Increased tone
– Constant fisting >3 months of age
– Scissoring
– Equinus position of feet, toe walking
– Extensor tone in supine position
– Spastic hand approach and grasp
– Persistent and sustained clonus
• “Changing tone” baby
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Approach to a child with
41 neurodevelopmental disability
2004
42
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Red flags (4)
Infancy/ early childhood
• Delayed appearance of postural reflexes and
developmental milestones
• Increased associated tone and movements in one
limb (paretic limb)
• Visual problems
– no visual following, persistent squint
• Lack of social/Comunicative skills
– Lack of auditory response, delayed speech,
avoiding eye contact, repetitive behavior, desire
for sameness, social isolation, lack of imaginative
play
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Essential to remember!
• Periodic repeated exams
• Clinical pattern of CP evolves over time:
– hypotonia
dystonia → dyskinesia
• Testing intelligence using conventional tests often
erroneous in CP:
– Associated motor problems, visual, auditory
and speech deficits
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