Peadiatric Rehabilitation -course-book

LA TIKA ROY FOUNDATION

Paediatric Rehabilitation
Therapy Course
Handbook for interdisciplinary therapy
Nalin Kumar (PT)

Arju Bala (PT)

16- 27 August 2010

2010

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4/3A,VASANT VIHAR ENCLAVE,DEHRADUN,UTTARAKHAND

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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 44
VI. ICF
13 VII. Goal making in early intervention therapy 45

14 VIII. Sensory Processing Disorder Checklist 47

15 IX. Oromotor Rehabilitation 66

16 X. ADL’s of Children with disability 84

17 Bobath Concept- Techniques of Proprioceptive and 85
Tactile Stimulation

18 XI. Neuro Developmental Therapy(NDT) 91

19 XII. Conductive Education 105

20 XIII. Play 106

21 XIV. Biological and Physiological importance of various 108
postures

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22 XV. Wooden furniture/equipments used in therapy 109

23 XVI. Do’s and Don’ts in CP 113

24 XVII. Checklist 115

Chair cum standing frame

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 child’s 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 body’s 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 Hands open

Rolls back to side Grasps/holds an object

Puts weight on arms while on tummy Hands play at midline

Month 4 Sits on propped arm Reaches with both arms/hands

Rolls tummy to side Brings fingers/hands in mouth

No head lag seen when pulled to sit Squeeze grasp emerging

Month 5 Rolls tummy to back Reaches with good aim

Wiggles few feet forward

Pushes up with arms while on belly

Sits propped on hands

Month 6 Sits independently for a brief period Reaches precisely and grasps objects

Sits in a highchair Transfers toys from hand to hand

Rolls over both ways Bangs a cup on a table

Month 7 Sits unsupported for ~30 seconds Crosses midline when reaching

Rocks on all fours Uses whole hand to rake in objects

Pivots in a circle while on tummy Thumb to finger grasp emerging

Month 8 Transitions tummy to sit Bangs cubes together

Crawls forward Uses a three-fingered grasp

Reaches while on tummy

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Month 9 Transitions sit to tummy Uses thumb to index finger
grasp(crude)
Pulls to stand while holding on
Crude release of objects
Creeps on all fours
Drops toys and objects
Stands while leaning on furniture
Points index finger

Month 10 Cruises along furniture Pokes with fingers

Stands unsupported briefly Uses thumb to index finger
grasp(precise)
Transfers from crawl to sit
Stacks objects

Month 11 Stands unsupported Releases a cube at will

Walks with hands held Removes pegs from a pegboard

Month 12 First independent steps Puts objects in a container

Stands unsupported~12 seconds Releases an object precisely

Assumes/maintains kneeling Stacks two one-inch cubes

12-15 Months Walks independently Throws objects

Creeps/climbs stairs Places rings on a peg

Tries to climb out of highchair Holds large crayon in fisted grasp

Squats to play Pulls large popbeads apart

Kneels Builds a 2 block tower

Stoops and recovers 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 / REFLEXES USE OF HANDS
MUSCLES

1-3 Head, neck & Keeps head to one side Large, jerky movements in Rooting Starts opening hand from
mon trunk: limbs time to time
hypotonicity Both arms & legs are flexed, Suckling
Limbs: hyper knees apart Arms more active than Starts bringing hand from
limbs Grasping side to midline
tonicity
Sole of feet turn inwards
Neck & Head control Hand opening
Keep hands closed (fist), thumb starts
turn in Flexor withdrawl
Movmt. Becomes smooth
Extensor thrust
& cont.
Crossed extension
Open hands time to time
Tonic Lab. supine

Cardinal points

3-6 Head: normal Postural stability of shoulder Kicks strongly Grasp Uses hands for grasp
mon girdle
Trunk: slight Moves legs alternately Moros Uses both hands,
hypotonic Raises head to look at feet occasionally one hand
Can roll from side to side Startle
Limbs: slight Good head holding Brings hands together
hypotonic Can bridge his hips off the Neck righting from sides into midline
Starts counterpoising the limbs in surface (5m)
the air Primitive squeeze
Tries to sit
Radial Palmar

6-9 Head: normal Posture stability of pelvis Child holds a leg up in air Raking movt. Try to grasp foot by hand
mon in order to grasp his foot
Trunk: normal Can lie straight with his hand Startle Manipulate toys

Limbs: Can turn his head easily Supine to side lying Moros Begins to point at object
with index finger
normal Try to sit from side lying Tilt reaction
Pass toy from hand to
Rolling & rising sequence Saving reaction hand
of motion
Release toys by dropping

9-12 Normal tone Good postural stability: Very active and controlled Landau’s Puts hands around bottle
mon movements of body & when feeding
Head & Neck stability limbs Pincer
Try to grasp spoon
Shoulder stability Pulls himself to sitting Tilt reaction
from side lying Clapping

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Pelvic stability Turns body to look Saving reaction Drops & throws objects
sideways
Shake toys to make noise

Takes object to mouth
less often

12-18 Normal tone Head in center or side (supine As child has learnt to sit, Landau’s Turn pages (thick) of
mon position) stand and walk, he/she no books
longer prefers supine Pincer
Arms/Legs can be flexed or position Feeds himself with
extended when in supine Tilt reactions assistance

Saving reactions Likes throwing objects
one by one

18-24 Normal tone Lie (supine & prone) Functional sitting and Mostly voluntary Can lift objects, throw
mon walking movements objects forcefully
Sit
Movements get more Landau’s Refined grasp and
Stand refined scribbling

2-5 Normal tone Use supine position to rest and Use supine position to Voluntary movements Further precision – writing
yrs sleep rest and sleep & drawing

Fully functional

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Prone Posture

MUSCLES

1-2 Limbs: hyper Neonate: in prone, the baby Reflexive movements. 0-2month- Gallant’s Newborn: the primitive
mon tonicity prevails in promptly turns his head Can flex upper limb and trunk incurvation. grasp reflex present.
flexor muscles. sideways, his cheeks resting on lower limb with greater
the tabletop. The buttocks are suppleness. 1-4 months- 1m. –The reflex is still
Head, neck & humped up, with the knees present.
trunk: Limited range, a) Cross- extension
flexed under the abdomen. The
hypotonicity predominantly flexion. reflex. 2m. –The reflex is less
arms are close to the chest with
prevails / slack / apparent and his hands
the elbows fully flexed.
Can raise his head to 45 b) Tonic -labyrinthine- are quite often open.
no muscular tone.
from the plane of the bed. prone.
1month - same with hands under
the abdomen and arms & legs
c) STNR
flexed, elbows away from body,
buttocks moderately high.

3-4 Limbs: Lifts head and upper chest wall At 4 months: does 1-4 months- ‘Grasping on contact’, the
mon hypertonicity up in midline, using forearms to swimming, flexing and child involuntarily grasps
becoming support & (often) actively extending all his limbs. a) Cross- extension an object placed in
hypotonicity scratching surface with hands; reflex. contact with his hands.
leading to buttocks flat Raises himself on his
forearms/ elbows and can b) Tonic -labyrinthine-
extension in upper
Disassociation of head from raise his head to 45 and prone.
limb and lower
limb. shoulders; working against 90 from the plane of the
c) STNR
gravity bed
Head and trunk:
hypotonicity Strengthening of neck
becoming normal. muscles
3mo-2.5 years:
Landau’s reflex

5-6 Limbs: normal Placed in prone, lifts head and Lying on his abdomen, he 4-6 months- Righting Lying flat on his abdomen,
mon tone. Head chest wall up supporting himself becomes an aeroplane, reactions-Amphibian. the forearms are
and trunk: very on flattened palms and extended supporting his weight on hyperextended in front of
firm / further arms. his thorax; he raises his the infant and his hands
increase in tone. arms and legs. flat on the ground. He
Hip-anchoring 3mo-2.5 years:
cannot yet use them to
Rolls from abdomen to his Landau’s reflex
play with but raises
back. himself up on hands.

Co-contraction of muscles
6 month onwards: Tilt
in upper arm
reactions

(General rule: Concavity
on higher side)

7-8 Limbs: normal Placed in prone, lifts head and Easily roles over in both 3mo-2.5 years: Raise one hand from
mon tone. Head chest wall up supporting himself directions (back to Landau’s reflex ground to take hold of a
and trunk: normal on flattened palms and extended abdomen and abdomen cube.
tone. arms. to back).
Passes cube from one

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Go from complete flexion in hips When lying on his 6 month onwards: Tilt hand to other, bangs
to mid-flexion abdomen, he can raise up reaction them together and on the
his entire body on his ground.
hands and knees.
Releases objects
7-12 month onwards: voluntarily with movmt.
Four-point kneeling of whole hand.

Grasps an object between
thumb and little finger.
Saving reactions

9-10 Limbs: normal Crawling posture – taking weight Pivots body using limbs to 3mo-2.5 years: Grasp objects between
mon tone. Head on hands and knees right/left. Landau’s reflex base of thumb and fore
and trunk: normal finger.
tone. Achieves sit from hands and The infant tries to crawl
knees: Side sitting, W sitting on his stomach & Pulls an object by string.
progresses to walking on 6 month onwards: Tilt
all fours (hands & knees). reaction Likes to throw objects.

He starts by going
backwards.
7-12 month onwards:
Four-point kneeling

Saving reactions

11-12 Limbs: normal Half kneels with hand supports Crawls reciprocally 3mo-2.5 years: Grasp improves further.
mon tone. Head Landau’s reflex Can release objects with
and trunk: normal Rises to upright kneeling with Bear walk – the infant fine & precise
tone. hand supports walks more confidently on Tilt reaction movements.
all fours (hands & feet).
Bear-walk posture – weight on 4-point kneeling Points to objects with
hands and feet forefingers.
Saving reactions

15 Limbs: normal Kneels unaided or with slight Inclined crawling- climb 3mo-2.5 years: Makes towers of 2cubes.
mont tone. Head support in prone the stairs on all fours. Landau’s reflex
hs and trunk: normal Smoothly moving from Turn pages of a picture
&abo tone. Half kneels upright no support ext/flex to co- Tilt reaction book.
ve (against gravity, extension at the contractions.
pelvis) 4-point kneeling
Knee walks forward
Saving reactions

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Sitting Posture

AGE TONE POSTURE MOVEMENT PATTERN REFLEXES USE OF HANDS
/ MUSCLES

Neon Limbs: hyper Held sitting – back and head Flexion in total body Grasp reflex Primitive grasp reflex
ate tonicity uncontrolled
Hand opening
Head, neck &
trunk: Foot grasp
hypotonicity
Head righting

2mon Limbs: Held sitting – head remains Head and neck Automatic sitting – Tracking occurs with eye
ths hypertonicity upright for few moments but extended but control protraction of shoulder but hand control not
becoming wobbles not present girdle present
hypotonicity -
extension in upper Back – flexed
and lower limb.
Hips – slight ext.
Head and trunk:
hypotonicity
becoming normal.

3mon Head and neck: Held sitting – head & neck Head & Neck – Labyrinthine head & Clumsy reaching –
ths normal tone straight. extended to vertical vestibular righting reflex bilateral

Trunk: Back firm but lumbar region still Lumbar kyphosis Grasps objects placed in
Hypotonicity weak present hand, thumb adducted

Limbs: normal Head control in supine &prone Increased extension of
tone position upper and lower limbs

4-6 Tone is normal in Postural fixation of head on Head & neck - Saving & propping Reaching in all directions
head, neck, trunk shoulder girdle extended/vertical reactions in forward
mont &limbs direction Bilateral to unilateral
hs Sitting with support, back Hips extended reach
straight, legs straight turning out
and apart Legs extended Thumb pressed in
opposition
Sitting on baby chair with back & Sitting lean on both
sides supported or propped on a hands, forward with Ulnar/palmar grasp
pillow support less support
Wrist flex./ext.

6-7 Tone is normal Postural fixation of trunk on Head, neck – extended Saving & propping Manipulate toys with one
mont pelvis reactions in forward hand & use other hand for
hs Back – bent to flexion direction support
Sitting lean on hands
Arms extended Unilateral reach & grasp
Lift one hand to play with toys
Hips – flexed, abducted Beginning radial grasp
& ext rotated

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Knees flexed

7-8 Tone is normal Sitting, reach in all directions; Trunk – more control so Saving & propping Use hands to save in
mont hand support sideways rotation is possible reactions in sideways forward and side
hs direction directions
Upper limb – all
movements, ext. in one Pats images of face in
arm, flex in other mirror

Lower limb –

Rotation in hip

8-9 Tone is normal Sitting without external support, Head, neck, trunk & Tilt reactions in forward, Manipulation with both
mont may use hand for support upper limb – variety of sideways & backward hands (bilateral &
hs motions directions unilateral)

Lower limb – control Saving & propping
improved reactions in sideways
direction
Full ext. of hip still not
possible

9-12 Tone is normal Turn to play, reach, no self hand Co-contraction of neck Tilt reactions in forward, Point with index finger
mont support & trunk sideways & backward
hs directions Reach and grasp in all
Sitting to various positions – Trunk/Pelvic directions
round sitting, long sitting, side disassociation Saving & propping
sitting, W sitting, cross legged, reactions in sideways Pick & place objects in &
stool/chair sitting Hips - anchoring is direction out of large container
complete; wt. shifting.
rotation

Rising out of sitting and
getting into all sitting
positions

1-5 Tone is normal Various postures can be attained Various muscle Saving reactions Hand manipulation is
years activities can be completely developed refined
performed because of
better control &
coordination

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Upright Posture

MUSCLES

0-3 Head, neck & Trunk supported – Plantigrade Hip slight flexion Flexor withdrawl No hand function
mont trunk: hypotonic feet
hs Knee extension Crossed extension
Limbs: Flexor tone
in lower limbs, Ankle neutral Placing reaction
extensor tone
No pelvic stability Automatic walk
developing in
knees

3-6 Head: normal Bears some weight Hip extension Positive supporting Uses hands for grasp
mont (3m)
hs Trunk: slight Trunk support is required Knee hyper ext. Uses both hands,
hypotonic Negative supporting (3- occasionally one hand
Ankle – plantar flex. 5m)
Limbs: slight Brings hands together
hypotonic Simultaneous contraction Foot grasp from sides into midline
of opposing muscle
groups started (co-
contraction)

6-9 Head: normal Stands with forearm leaning and Hips – both flexors and Placing reaction more Use hands as support
mont pelvis support extensors contract predominant while standing
hs Trunk: slight simultaneously (co-cont)
hypotonic When standing by holding- hips Saving reaction In saving, use hands for
may flex, feet are flat Toes flexion protection
Limbs:

normal

9-12 Normal tone Pulls self to stand Reciprocal contraction of Saving reaction Counterpoising
mont opposite muscle
hs Cruises using two hands Saving
Abduction & adduction of
Stands, holds one hand & can hips while cruising Both arms for holding
reach in all directions with other
Support & bear weight for
Can lift one leg cruising

12-18 Normal tone Stands, stoops and recovers Extension of hip, knee, Tilt reaction – trunk Walking – hand for
mont ankle (neutral) while support, 2 hand to 1 hand
hs Stands without support standing Staggering – forwards, hold
sideways, backwards
Contraction of hip Carry objects while
extensors of one limb & Counterpoising without walking
flexors of other limb while holding
standing (1 limb) Use hand for rising

Simultaneous contract. of Support while stair

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flex/ext climbing

Abd/flex/ext of hip while
staggering

18-24 Normal tone Stand alone, runs Co-contraction of flex/ext Normal Use hands freely for
mont manipulating
hs Turns (pivots) Reciprocal leg function
while running One hand support for
(dissociation) climbing

Rotation of hip & trunk Can use hands for playing
while turning while walking or standing

Reciprocal limb movmt.
while climbing

2-3 Normal tone Running Symmetrical contraction Normal No support required
yrs & relaxation of both limbs
Climbing stairs while jumping Use hands simultaneously
for manipulation
More refined jumping Limb dissociation –
reciprocal movmt. of Play-catches ball
limbs

3-4 Normal tone Stands on preferred leg, 5-10secs Extension of preferred leg Normal Play
yrs
Heel to toe stand Flexion of leg More refined
counterpoising
Dorsiflexion – neutral -
plantarflexion

Hyperextension in trunk

Flex./Add. Of upper limb

4-5 Normal tone Balance on one leg (10sec) Extension and adduction Normal Play
yrs of hip
Walks on narrow line More refined
Counterpoising counterpoising

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.

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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 Stimulus Response Contribution
until
1. Sucking 3 mon Introduce finger into Sucking action of lips and jaw Development of oral
mouth 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 2 mon a)Touch corner of a) Bottom lip lowers on same side and Helps to locate nipple.
points mouth tongue moves towards point of Develops lateralisation of
stimulation. When fingers slide away, the tongue.
b)center of upper lip head turns to follow.
stimulated
b) Lip elevates, tongue moves towards
c)Center of bottom lip place stimulated. If finger slides along
is stroked. 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.

4. Grasp 3 Mon Press finger on Ulnar Fingers flex and grip objects (head in Development of flexor
side of palm midline during rest) tone on hand and upper
extremities.

5. Hand 1 mon Stroke Ulnar border Automatic opening of the hand. The baby learns extension
opening of palm and little movement of finger
finger

6. Foot grasp 9 mon Press sole of foot Grasping response of feet Helps baby to grasp the
behind the toes surface when held in
standing

7. Placing Remains Bring the anterior Child lifts limbs up to step onto table. Helps to place foot in the
aspect of foot or hand appropriate position for
against the edge of standing and locomotion.
table. Ability to place the hand
and upper extremity in a
position for support in
sitting and quadruped
position.

8. Primary 2 mon Hold baby upright and Initiates reciprocal flexion and extension It indicates the potential
walking tip forwards, sole of of legs. for automatic reciprocal
foot press against walking.
table.

23


9. Galant’s 2 mon Stroke back lateral to Flexion of trunk towards the side of Initiates unilateral trunk
trunk the spine. stimulus. mobility.
incuvation
Creates asymmetrical
pattern of movement.
Initial movement for
rotation initiates
amphibian movement
necessary for creeping,
crawling breaks up
symmetrical pattern of
movement.

10. Automatic 2 mon Pressure id placed on Child pulls to sitting from supine Weight bearing in
Sitting the thighs and the development of standing.
head is held in
flexion, supine
position.

11. Moro 0-6 months Baby supine and back Abduction and extension of arms. Hands Develops extensor tone
of head is supported open. This phase is followed by bilaterally in upper
above table, drop adduction of arms as if in embrace. extremities and fingers.
head backwards, As this reflex matures and
associated with loud integrates the upper
noise. extremities are prepared
for propping and
parachute reaction.

12. Startle Remains Obtained by sudden Elbow is flexed (not extended as in Helps as protective
loud noise or tapping Moro) and hand remains closed. function.
the sternum

13. Landau 3 months to 2 Child held in ventral The head,spine and legs extended. Develops extensor tone in
½ years, suspension, head lift Extended arms and shoulders. the neck musculature of
strong 10 the neck to the trunk to
months 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 2 months Supine; head mid Uncontrolled flexion response of Helps in protective
withdrawal line;legs extended- stimulates leg(do not confuse with reaction.
stimulates sole of foot response to tickling)
Helps to develop between
flexor and extensor tone.

15. Extensor 2 months Supine; head mid Uncontrolled extension of stimulated leg Helps in extensor tone in
thrust position, one leg (do not confuse with response of tickling) legs.
extended opposite leg
flexed-turn head to

24


one side

16. Crossed 3 months Supine, head , mid Opposite leg adducts, extends, internally Develops alternative
extension position, legs rotates, foot planter flexes (typically extensor tone in the lower
extended stimulate scissor position). extremities breaks up
medial surface of one symmetrical flexion and
leg by tapping extension movement,
precursor to amphibian
movement in preparation
for creeping and crawling
and walking pattern

17. ATNR 6 Months Baby supine, head in Extension of arm and leg on face side, or Breaks symmetrical
mid line, arms and increase in flexor tone. flexion/extension pattern
Usually legs extended- turn of movement. Enables
pathological head to one side each side of body
separately.

18. STNR Rare and 1) Baby is quadruped Arms flex or flexor tone dominates. Helps in creating a
usually position or over balance between flexor
pathological tester’s knees- and extensors for stable
ventroflex the head. position against gravity.

2)Position as above Helps in developing prone
dorsiflex the head An arm extendes or extensor tone on elbows to extended
dominates; legs flex or flexor tone elbows to 4 foot
dominates. quadruped to reciprocal
crawling

19. Tonic Pathological Baby supine, head in Extensor tone predominates when the Develops extensor tone
Labyrinthine mid position; arms arms and legs are passively flexed throughout body.
supine and leg extended, test
stimulus is the Creates ability to reach.
position.
Brings limbs to mid line,
cross midline.

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

20. Tonic 3 months Baby prone; head in Unable to dorsifles head, retract Stimulation of flexor tone
Labyrinthine mid position.Test shoulders, extend trunk, arms, legs. of the total body, helps to
prone stimulus- prone counter balance the
postion. extensor tone in supine.

This gives stability to
proceed prone
development.

21. Positive 3 months Hold baby in standing Increase of extension in legs, planter Helps to develop co-
supporting position press down flexion, genu recurvatum may occur. contraction of flexor and
the soles of feet extensor necessary for
standing.

22. Negative 3-5 months Hold in weight Baby ‘sinks’ ataxia Allows the child for
supporting bearing position voluntary weight bearing.

25


23. Neck 5 months Supine, rotate head to Body rotates in same direction as the It initiates rolling(Log
righting one side, actively or head. rolling)
passively

24. Associated pathological Have baby squeeze an Clench of other hand or increase of tone
reaction object(with involved in other parts of body. Abnormal
side) overflow.

26


Righting Reactions
S.No Reaction Emerges at Stimulus Response Contributions

1. Amphibian 4-6 Months Baby in prone, head in mid Automotive flexion Initiates to attain
position, legs extended, lifts outward of hip and quadruped position and
pelvis on one side. knee on same side. crawling.

2. Body righting 6- 10 Months If the child rotates hip and Active segmental Dissociation of head and
reaction knee (on arm on head reaction. limb occurs which helps in
actively) crawling, walking etc.

3. Body righting 4 -6 Months Baby in supine rotate head( Active derotation at 1) Segmental contraction f
derotative on one side) Knee on one waist is segmental trunk, neck, hip & leg
side rotation of trunk muscles.
between shoulders and
pelvis. 2) Dissociation of trunk
and limb helps in crawling
and later walking.

4. Labyrinthine head 2-6 1) Hold the baby Head raises to normal These reactions help to
righting vestibular blindfolded in prone in position, face vertical attain antigravity position.
righting Months supine, as head drops. mouth horizontal.

2) Hold the baby Head raises to normal
blindfolded in supine, in position, face vertical
space, as head drops. mouth horizontal.

3) Hold the baby Head rights itself to
blindfolded, hold around normal position, face
pelvis and tilt it to one side. vertical mouth
horizontal.

5. Optical righting 6 Months Hold baby either in supine Head raises t normal Helps to attain antigravity
(or in prone, in space as position face vertical posture.
head drops) mouth horizontal.

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Equilibrium Reaction
S.No Reaction Emerges at Stimulus Response Contribute

1. Tilt Reactions 6 Months Baby on tilt board, arms and Lateral curving of head and All the equilibrium
legs extended, tilt the board thorax, parachute reaction in reactions are protective.
Supine and Prone on one side. limbs accompany trunk They facilitate the body to
rotation. maintain various body
postures external force
and balance in dynamic
postures.

2. Four point kneeling 7-12 months Child in Quadruped position a) Lateral curving of head and Do-
thorax.
a) Tilt towards one side.
Abduction extension of arms
b) Tilt forwards. and legs on raised side and
protective reactions on
c)Tilt backwards lowered side may accompany
this.

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

3. Sitting 9-12 months Baby seated n chair Head and thorax curve, Do-
abduction-extension of arms
a)Tilt the child to one side and legs on raised side and
protective reactions on
b) Tilt the child forward. lowered side may accompany
this.
c) Tilt the child backward.
Child extends head and back.
a)
Child flexes head and back.

4. Kneel standing 18 months Child in kneel sitting position. Head and thorax curve, Do-
abduction- extension of arm
Tilt to one side and leg on raised side, other
protective reaction may
accompany this.

5. Standing 12-18 Child in standing position a) Head and thorax curve Do-
months abduction extension of arms
a)Tilt sideways and leg on raised side, other
protective reactions may
accompany this.

b)Tilt forwards

c) Tilt Backwards

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II c. Contribution of Reflexes
1. Gallant’s 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

29


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
30


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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