1. Pediatrics
The branch of Medicine that
deals with any disturbances
of the health or the orderly
growth and development of
the child.
A report by:
Kenneth Pierre M. Lopez
3. Development
The sequence of events through which the individual
grows, changes, evolves and matures
Theories of Development
Maturationist Theory
Individual genetically and biologically determined
There are preformed innate aspects of human
behavior
Empiricist Theory
Source of human behavior is the environment
Behavioral Theory
Environmental reinforcement is the motivator and
shaper of cognitive and motor behavior
Used in behavior modification treatment where
desired behaviors are positively reinforced and
unwanted behaviors are ignored
4. Interactionist Theory
Child is an active social being who contributes
to his development
Piagetian Theory
Interaction of environment and neural
maturation results in spiraling of development
with equilibrium and disequilibrium resulting.
5. Motor Control
The study of postures and movements and parts of
mind and body which control posture and
movement.
Theories of motor control
Neuromaturationist theory
Cortex is command center with descending
control and inhibition of lower centers by higher
ones in central nervous system
Systems theory
Command center changes from cortex to other
levels depending on task
Stresses interaction between brain, body and
environment including biomechanics and body
geometry
6. Sensory systems mature, become integrated and
connected to muscle coordination patterns starting
with visual system
Immature postures involve cocontraction of agonists
and antagonists, cocontraction decreases with
maturation
Neuronal group selection theory
Genetic code of species outlines limits of neural
network formation
Actual network formation results from individual
experience
Cell death of unexercised synaptic and
strengthening of synaptic connections selectively
activated
7. Principles of Motor Development
1. Occurs in cephalocaudal direction
2. Unrefined to refined movement
3. Stability to controlled mobility
4. Occurs in spiraling manner, with periods of
equilibrium and disequilibrium
5. Sensitive periods occur when infant/child is
especially affected by environmental input
9. Asymmetrical Tonic Neck Reflex (ATNR)
Stimulus: Head position, turned to one side
Response: Arm and leg on face side are extended, are
and leg on scalp side are flexed, spine curved with
convexity toward face side
Normal age of response: Birth to 6 months
Interferes with:
Feeding
Visual tracking
Midline use of hands
Bilateral hand use
Rolling
Development of crawling
Can lead to skeletal deformities (scoliosis, hip
subluxation/dislocation)
10. Symmetrical Tonic Neck Reflex (STNR)
Stimulus: Head position, flexion or extension
Response: When head is in flexion, arms are flexed,
legs extended. When head is in extension, arms
extended, legs are flexed
Normal age of response: 6 to 8 months
Interferes with:
Ability to prop on arms in prone positions
Attaining and maintaining hands and knees
position
Crawling reciprocally
Sitting balance when looking around
Use of hands when looking at object in hands in
sitting position
11. Tonic Labyrinthine Reflex (TLR)
Stimulus: Position of labyrinth in inner ear- reflected
in head position
Response: In the supine position, body and
extremities are held in extension; in the prone
position, body and extremities are held in flexion
Normal age of response: Birth to 6 months
Interferes with:
Ability to initiate rolling
Ability to prop on elbows with extended hips when
prone
Ability to flex trunk and hips to come to sitting
position from supine position
Often causes full body extension, which interferes
with balance in sitting or standing
12. Galant Reflex
Stimulus: Touch skin along spine from
shoulder to hip
Response: lateral flexion of trunk to side of
stimulus
Normal age of response: 30 weeks of
gestation to 2 months
Interferes with:
Development of sitting balance
Can lead to scoliosis
13. Palmar Grasp Reflex
Stimulus: Pressure in palm on ulnar side of hand
Response: Flexion of fingers causing strong grip
Normal age of response: Birth to 4 months
Interferes with:
Ability to grasp and release objects voluntarily
Weight bearing on open hand for propping,
crawling, protective response
14. Plantar Grasp Reflex
Stimulus: Pressure to base of toes
Response: Toe flexion
Normal age of response: 28 weeks of
gestation to 9 months
Interferes with:
Ability to stand with feet flat on surface
Balance reactions and weight shifting in
standing
15. Rooting Reflex
Stimulus: touch on cheek
Response: Turning head to same side with
mouth open
Normal age of response: 28 weeks of
gestation to 3 months
Interferes with:
Oral-motor development
Development of midline control of head
Optical righting, visual tracking, and
social interaction
16. Moro Reflex
Stimulus: Head dropping into extension suddenly
for a few inches
Response: arms abduct with fingers open, then
cross trunk into adduction; cry
Normal age of response: 28 weeks of gestation to
5 months
Interferes with:
Balance reactions in sitting
Protective responses in sitting
Eye-hand coordination, visual tracking
17. Startle Reflex
Stimulus: Loud, sudden noise
Response: Similar to Moro response but
elbows remain flexed and hands closed
Normal age of response: 28 weeks of
gestation to 5 months
Interferes with:
Sitting balance
Protective responses in sitting
Eye-hand coordination, visual tracking
Social interaction, attention
18. Positive Support Reflex
Stimulus: weight placed on balls of feet when
upright
Response: stiffening of legs and trunk into
extension
Normal age of response: 35 weeks of
gestation to 2 months
Interferes with:
Standing and walking
Balance reactions and weight shift in
standing
Can lead to contractures of ankles into
plantar flexion
19. Walking (Stepping) Reflex
Stimulus: Supported upright position with soles
of feet on firm surface
Response: Reciprocal flexion/extension of legs
Normal age of response: 38 weeks of
gestation to 2 months
Interferes with:
Standing and walking
Balance reactions and weight shifting in
standing
Development of smooth, coordinated
reciprocal movements of lower extremities
21. Newborn to 1 Month
Gross Motor Skills Fine Motor Skills
Prone Regards objects in
Physiological flexion
direct line of sight
Lifts head briefly
Head to side Follows moving object
Supine
to midline
Physiological flexion Hands fisted
Rolls partly to side Arm movements jerky
Sitting
Movements may be
Head lag in pull to sit
purposeful or random
Standing
Reflex standing and
walking
22. 2 to 3 months
Gross Motor Skills Fine Motor Skills
Prone Can see further
Lifts head 90degrees briefly
Chest up in prone position distances
with some weight through
forearms Hands open more
Rolls prone to supine
Visually follows through
Supine
ATNR influence strong 180 degrees
Legs kick reciprocally
Grasp is reflexive
Prefers head to side
Sitting Uses palmar grasp
Head upright but bobbing
Variable head lag in pull to sit
Needs full support to sit
Standing
Poor weight bearing
Hips in flexion, behind
shoulders
23. 4 to 5 months
Gross Motor Skills Fine Motor Skills
Prone Grasps and releases
Bears weight on extended
toys
arms
Pivots in prone to reach toys Uses ulnar-palmar
Supine grasp
Rolls from supine to side
position
Plays with feet to mouth
Sitting
Head steady in supported
sitting position
Turns head in sitting position
Sits alone for brief periods
Standing
Bears all weight through legs in
supported stand
24. 6 to 7 months
Gross Motor Skills Fine Motor Skills
Prone Approaches objects
Rolls from supine to prone with one hand
position
Holds weight on one hand Arm in neutral when
to reach for toy approaching toy
Supine
Radial-palmar grasp
Lifts head
Sitting “rakes” with fingers to
Lifts head and helps when pick up small objects
pulled to sitting position Voluntary release to
Gets to sitting position
without assistance transfer objects
Sits independently between hands
Mobility
May crawl backward
25. 8 to 9 months
Gross Motor Skills Fine Motor Skills
Prone Develops active
Gets into hands-knees position
supination
Supine
Does not tolerate supine Radial-digital grasp
position develops
Sitting
Moves from sitting to prone Uses inferior pincer
position grasp
Sits without hand support for
longer periods Extends wrist actively
Pivots in sitting position
Points with index finger
Standing
Stands at furniture Pokes with index finger
Pulls to stand at furniture
Release of objects is
Lowers to sitting position from
supported stand more refined
Mobility Takes objects out of
Crawls forward
Walks along furniture (cruising)
container
26. 10 to 11 months
Gross Motor Skills Fine Motor Skills
Standing Fine pincer grasp
Stands without support development
briefly
Pulls to stand using half- Puts objects into
kneel intermediate container
position
Grasps crayon
Picks up object from floor
from standing with adaptively
support
Mobility
Walks with both hands
held
Walks with one hand held
Creeps on hands and
feet (bear walk)
27. 12 to 15 months
Gross Motor Skills Fine Motor Skills
Mobility Marks paper with
Walks without crayon
support
Builds tower using
Fast walking
two cubes
Walkst backward
Walks sideways
Turns over small
Bends over to look
container to
between legs obtain contents
Creeps or hitches
upstairs
Throws ball in sitting
28. 16 to 24 months
Gross Motor Skills Fine Motor Skills
Squats in play Folds paper
Walks upstairs and Strings beads
downstairs with one
Stacks six cubes
hand held-both feet
on step Imitates vertical and
Propels ride-on toys horizontal strokes
Kicks ball with crayon on
Throws ball
paper
Throws ball forward Holds crayon with
Picks up toy from
thumb and fingers
floor without falling
29. 2 Years
Gross Motor Skills Fine Motor Skills
Rides tricycle Turns knob
Walks backward Opens and closes
jar
Walks on tiptoe
Able to button large
Runes on toes buttons
Walks downstairs Uses childe-size
alternating feet scissors with help
Catches large ball Does 12 to 15 piece
Hops on one foot puzzles
Folds paper or
clothes
30. 3 to 4 Years
Gross Motor Skills Fine Motor Skills
Throws ball 10 feet Controls crayons
Walks on a line 10 more effectively
feet Copies a circle or
Hops 2-10 times on cross
one foot Matches colors
Jumps distances of Cuts with scissors
up to two feet Draws recognizable
Jumps over obstacles human figure with
up to 12 inches head and two
Throws and catches extremities
small ball Draws squares
Runs fast and avoids May demonstrate
obstacles hand preference
31. 5 to 8 Years
Gross Motor Skills Fine Motor Skills
Skips on alternate feet
Hand preference is
Gallops
evident
Can play hopsotch,
controlled hopping, Prints well, starting
and squatting on one
leg to learn cursive
Jumps with rhythm, writing
control (jump rope)
Able to button small
Bounces large ball
Kicks ball with greater
buttons
control
Limbs growing faster
than trunk allowing
greater speed,
leverage
33. Cerebral Palsy
An umbrella term used to describe movement
disorders due to brain damage that are non
progressive and are acquired in utero, during birth or
infancy. The brain damage decreases the brain’s
ability to monitor and control nerve and voluntary
muscle activity.
34. Classifications of CP
By area of body showing impairment
One limb – monoplegia
Two lower limbs – diplegia
Upper and lower limbs on one side of the body -
hemiplegia
All four limbs – quadriplegia
By most obvious impairment
Spastic – increased tone, lesion of motor cortex or
projections from motor cortex
Athetosis – fluctuating muscle tone, lesion of basal
ganglia
Ataxia – ionstability of movment, lesion of the
cerebellum
35. Gross Motor Classification of Cp
Level I
Walk without restrictions, limitations in more advanced
gross motor skills
Level II
Walk without assistive devices; limitations walking outdoors
and in the community
Level III
Walk with assistive mobility device; limitations walking outdoors
and in the community
Level IV
Self-mobility with limitations; children are transported or use
power mobility outdoors and in the community
Level V
Self-mobility is severely limited even with the use of assistive
technology
36. Impairments for all classes of CP
Insufficient
force genration
Tone abnormality
Poor selective control of muscle activity
Poor regulation of muscle activity in anticipation of
postural changes
Decreased ability to learn unique movements
Abnormal patterns of movement in total flexion and
extension
Persistence of primitive reflexes
May interfere with normal posture and movement
May cause contractures and deformities
37. Spastic CP
Increased muscle tone in antigravity muscles
Abnormal postures and movements with mass
patterns of flexion/extension
Imbalance of tone across joints may cause
contractures and deformities, especially of hip flexors,
adductors, internal rotators and knee flexors, ankle
plantar flexors of the LE, scapular retractors,
glenohumeral extensors, and adductors, elbow flexors,
forearm pronators
Visual, auditory, cognitive and oral motor deficits may
be associated with spastic CP
38. Athetoid CP
Generalized decreased muscle tone, floppy baby
syndrome
Poor functional stability especially in proximal joints
Ataxia and incoordination when child assumes upright
positions with decreased BOS and muscle tone
fluctuations
Poor visual tracking, speech delay and oral motor
problems
Tonic reflexes such as ATNR, STNR, TLR may be
persistent, blocking functional posture and movement
39. Ataxic CP
Low postureal tone with poor balance
Stance and gait are wide based
Intention tremor of hands
Uncoordinated movement
Ataxia follows initial hypotonia
Poor visual tracking, nystagmus
Speech articulation problems
May occur with spastic or athetoid CP
40. Interventions & Goals
Very individualized, depending on abilities, age,
type of CP. Incorporate child and family in
intervention planning, implementation and goal
setting.
Focus on prevention of disability by minimizing
effects of impairment, preventing or limiting
secondary impairment such as contractures,
scoliosis.
Utilize static (positioning) and dynamic patterns of
movement opposite to habitual spastic patterns
Facilitate symmetry in postures
Elongate spastic hamstrings and heel cords
Serial casting may be used to increase length of
muscle and decrease tone
41. Emphasize maximizing gross motor functional level
Use principles of motor learning and motor
control; facilitate the attainment of functional
motor skills including voluntary movement,
anticipatory and reactive postural adjustments.
Use toys, fun activities, balls and bolsters to
facilitate postural control and developmental
activities
Use weight-bearing and postural challenge to
increase muscle tone and strength
Incorporate orthoses and adaptive equipment
as necessary
42. Down Syndrome (Trisomy 21)
Chromosomal abnormality caused by breakage
and translocation of piece of chromosome onto
normal chromosome
43. Description
Milder form with some normal cells interspersed
with abnormal cells, called mosaic type
Brain weight decreased when compared with
normal
Cerebellum and brain stem lighter than normal
Smaller convolutions of cortex
44. Impairments
Hypotonia
Decreased force generation of muscles
Congenital heart defects
Visual and hearing losses
Atlantoaxial subluxation/dislocation possibly be
due to laxity of transverse odontoid ligament
Signsinclude decreased strength, ROM, DTR, and
sensation in extremities. This is a medical emergency
Cognitive deficits (mental retardation)
45. Functional Limitations
Gross motor developmental delay
Difficulties in eating and speech development
because of low tone
Forceful neck flexion and rotation activities should
be limited due to atlantoaxial ligament laxity
Cognitive and perceptual deficits may result in
delay of fine motor and psychosocial
development
46. Interventions & Goals
Minimize gross motor delay
Facilitate gross and fine motor development through
appropriate positioning, posture and movement activities
Increase strength and stability by manipulating gravity
and resistance in a graded manner
Encourage oral motor function
Facilitate lip closure and tongue retrusion
Short, frequent feeding sessions for energy conservation
Avoid hyperextension of elbows and knees during weight-
bearing activities
Prognosis may be correlated with tone; the lower the
tone, the more significant the motor delay
All children with Down syndrome will eventually become
ambulatory
47. Duchenne’s Muscular
Dystrophy
A progressive disorder caused by the absence of
the gene required to produce the muscle proteins
dystrophin and nebulin. Causing cell membranes to
weaken and destroy myofibrils and muscle
contractility is lost.
48. Pathology
X-linkedrecessive, inherited by boys, carried
by recessive gene of mother. Diagnosis
confirmed by clinical examination, EMG,
muscle biopsy, DNA analysis and blood
enzyme levels.
Dystropin gene missing results in increased
permeability of sarcolemma and destruction
of muscle cells
Collage, adipose laid down in muscle
leading to pseudohypertrophic calf muscles
49. Impairments
Progressive weakness from proximal to distal
beginning at 3 years of age to death in late
adolescence or early adulthood
Positive Gower’s sign because of weak
quadriceps and gluteal muscles; child must
use upper extremities to “walk up legs” to
rise from prone to standing
Cardiac tissue also involved
Contractures and deformities develop due
to muscle imbalance, especially of heel
cords and tensor fascia latae, as well as
lumbar lordosis and kyphoscoliosis
50. Functional Impairments
Developmental milestones may be
delayed
Ambulation ability will be lost,
necessitating use of wheelchair
eventually
Progressive cardiopulmonary
limitations
51. Interventions & Goals
Maintain mobility as long as possible
Maintain AROM/PROM, positioning
devices such as prone standers or
standing frames. Gastrocnemius and
TFL shorten first. Night splints may be
used.
ES of muscles
Educate parents and family in a
sensitive manner
Do not exercise at maximal level; may
injure muscle tissue (overwork injury)
52. Brachial Plexus Injury
• Traction or compression injury to the unilateral
brachial plexus during birth process or due to
cervical rib abnormality
• Nerve sheath is torn and nerve fibers compressed
by hemorrhage and edema, although total
avulsion of nerve is possible
53. 2 Types
Erbs Palsy C5-C6, upper arm paralysis
may involve rhomboids, levator
scapulae, serratus anterior, deltoid,
supraspinatus, infraspinatus, biceps
brachii, brachioradialis, brachialis,
supinator and long extensors of wrist,
fingers and thumb
Klumpke’s Palsy C8-T1, lower arm
paralysis, involves intrinsic muscles of
hand, flexors and extensors of wrist and
fingers
Erb-Klumpke’s Palsy, whole arm paralysis
54. Impairments
Sensory deficits of upper extremity
Paralysis or paresis of upper extremity
Characteristic position for Erb’s palsy of
upper extremity is adduction, IR and
extension of elbow , pronation of
forearm and flexion of wrist
55. Functional Limitations
Dependent on severity of injury
Erb’s palsy results in decreased shoulder
girdle function with 1:1 humeroscapular
movement
Klumpke’s palsy results in decreased wrist
and hand function
Traction injuries resolve spontaneously
Avulsion injury may require surgical nerve
repair if not resolved within three months
Shoulder subluxation and contractures of
muscles may develop
56. Interventions & Goals
Partial immobilization of limb across
upper abdomen for 1-2 weeks to avoid
injury
Gentle ROM after initial immobilization to
avoid contractures
Elicit muscle activity with age
appropriate functional movements of UE
May use gentle constraint of unaffected
arm to facilitate use of affected UE
Prognosis depends on severity of nerve
injury, favorable in most instances, if
recovery does not occur, surgery is
indicated
57. Myelodysplasia/Spina
Bifida/Hydrocephalus
Neural tube defect resulting in vertebral and/or
spinal cord malformation. Elevated serum or
amniotic alpha-fetoprotein, amniotic
acetylcholinesterase in prenatal period and
sonogram are used for detection
58. Types
Spina bifida occulta – no spinal cord
involvement may be indicated by a
tuft of hair, dimple or sinus
Spina bifida cystica- visible or open
lesion
Meningocele- cyst includes CSF; cord
intact
Myelomeningocele- cyst includes CSF
and herniated cord tissue
59. Pathology
Link between maternal decreased
folic acid, infection, hot tub soaks, and
exposure to teratogens such as
alcohol and valproic acid to neural
tube defects
Meningitiscommon if defect not closed
soon after birth
60. Pathology
Foot deformities such as talipes
equinovarus common, especially with
L4, L5 level
Tethered cord may lead to increased
severity of problems as child grows
Latex sensitivity/allergy
Hydrocephalus significantly related to
closure of neural tube defect. Shunting
done to relieve pressure of
hydrocephalus
61. Hydrocephalus
Abnormal accumulation of cerebrospinal
fluid (CSF) within the ventricles inside the
brain. Intracranial pressure (ICP) rises if
production of CSF exceeds absorption. This
occurs if CSF is overproduced, resistance to
CSF flow is increased, or venous sinus
pressure is increased
Congenital hydrocephalus is thought to be
caused by a complex interaction of
environmental and perhaps genetic factors
62. Primary Symptoms
Acquired hydrocephalus may result from
intraventricular hemorrhage, meningitis,
head trauma, tumor and cysts
Infants may have poor feeding, irritability,
reduced activity and/or vomiting
Children include a slowing of mental
capacity, drowsiness, headaches, neck
pain, visual disturbances, and gait
disturbances
63. Impairments
Muscleparalysis and imbalance resulting in spinal
and lower limb deformities and joint contractures
Kyphoscoliosis
Shortened hip flexors and adductors
Flexed knees
Pronated feet
L4,L5lesion results in bowel and bladder dysfunction
Sensory loss
Developmental delays
Abnormal tone- may have low tone which will lead
to poor strength and/or spasticity in upper
extremities
Osteoporosis
Cognitive impairments, mental retardation, learning
and perceptual disabilities, language disorders
64. Functional Limitations
Weakness or paralysis of hip flexors
(high lumbar level lesion) makes
ambulation possible only with
reciprocating gait orthosis (RGO)
Problems with learning and
communication
65. Interventions and Goals
Teach parents proper positioning,
handling and exercise, keeping
physiological flexion of the newborns,
include prone positioning to avoid
shortening of hip flexors as well as hip
ROM low tone and osteoporosis in mind
Use of adaptive equipment/orthoses
such as spinal orthoses for alignment,
adaptive chairs for sitting (if needed),
parapodium for early standing, lower
extremity orthoses and ambulation
assistive devices and/or wheelchair as
needed
66. Facilitation of functional motor
development including appropriate
developmental activities, primary or
voluntary movement as well as
reactive and anticipatory postural
adjustments
Educate parents regarding shunt
malfunction, signs include increased
irritability, increased muscle tone,
seizures, vomiting, bulging fontanels,
headache and redness along shunt
tract
67. References:
• National Physical Therapy
examination review & Study
Guide 2011; Susan O’
Sullivan; Raymond
Siegelman
• PT EXAM the complete
Study Guide; Scott M, Gilles
• IQ Physical and
Occupational Therapy
Reviewer
• McGraw-Hills NPTE; Mark
Dutton
