Exam 1 Flashcards
What is a reflex?
an involuntary, stereotyped response to a particular stimulus. They begin to develop in fetal life and continue to influence motor behavior throughout early infancy. In adults, reflex motor patterns continue to underlie the organized voluntary movements used in daily activities. Reflexes are tested according to developmental sequence and integration of the primitive reflexes is necessary for the development of purposeful movement.
Describe in general the reflexes that happen at the Brain Stem Level.
These reflexes involved sustained changes in muscle for the whole body or more than one part of the body. The changed tone is in response to a change of the position of the head in space or in relation to the body.
4 types: ATNR, STNR, TLR, associated reactions
Asymmetrical Tonic Neck Reflex
Normal Age Level: birth to 4 to 6 months
Test Position: patient is placed in supine position with the head in midline and the arms and legs are extended
Test Stimulus: turn head to one side
Negative Reaction: There is no reaction of the limbs on either side
Positive Reaction: extension of the arm and leg on the face side and flexion of the arm and leg on the skull side
Importance of reflex: This reflex promotes development of eye-hand glaze and contributes to the formation of reciprocal movements. However, if integration of this reflex does not occur it will prevent weight bearing by preventing: a) Rolling from supine to prone - 1)On the skull side of the scapula retracts preventing the arm from crossing midline. 2) On the face side the arm extends in the direction which rolling is attempted b) A loss of balance in a sitting or quadruped position due to flexion of extremities
Additional notes: In older kids, quadruped (wt bearing) turn head to one side –> bending of arm and ext of opp arm and leg
Symmetrical Tonic Neck Flexion
Normal Age: birth to 4 to 6 months of age
Test Position: patient is placed in a quadruped position or over the examiner’s knee
Test Stimulus flexion or extension of the head
Negative Response: no change in the tone of the arms or legs
Positive Response: a) flexion: the arms are flexed or flexor tone dominates and the legs extend or extensor tone dominates b) extension: the arms extend or extensor tone dominates and the legs flex or flexor tone dominates
Importance of Reflex: this reflex promotes four point kneeling by breaking up the extensor pattern. However, if integration of this reflex does not occur it will prevent weight bearing.
Additional notes: Positive Reactions may be subtle. Older kids –> quadruped–> lose balance
Tonic Labyrinthine Reflex
Normal Age Level: birth to 4 to 6 months
Test position: patient can either be placed in supine or prone position with head in midline and arms and legs extended
Test Stimulus: can either be placed in supine or prone position
Negative Reaction: a) supine - no increase in extensor tone when the arms and legs are passively flexed b) prone - no increase in flexor tone; the head, trunk, arms, and legs can be extended
Positive Reactions: a) Supine - extensor tone dominates when the arms and legs are passively flexed b) Prone - unable to extend the head, retract the shoulders; extend the trunk, arms, and legs
Importance of Reflex: this reflex allows the infant to log roll from the prone to the supine position. Rolling is accomplished by moving the head, the shoulders and the hips follow at one piece. However, if integration of this reflex does not occur it will prevent weight bearing and normal rolling.
Associated Reactions
Normal Age Level: these reactions occur normally throughout life
Test Position: patient is placed in supine position
Test Stimulus: examiner has patient squeeze an object
Negative Reaction: there is no reaction, or a minimal reaction or an increase of tone in other parts of the body
Positive Reaction: there is a mirroring of the opposite limb and/or an increase of tone in other parts of the body
Importance of Reflex: in normal development these reactions promote awareness of both sides of the body. however, if integration of these reactions does not occur they will interfere with bilateral hand movement
Generally describe reactions associated with the midbrain level.
The righting reactions interact with each other and work toward establishment of normal head and body relationship in space as well as in relation to each other
2 types: Neck righting and Body Righting
Neck Righting
Normal Age: birth to 6 months
Test Position: paitent is placed in a supine position with the head in midline and the arms and legs extended
Test Stimulus: the head is rotated to one side either actively or passively
Negative Reactions: the body will not rotate
Positive Reaction: the body rotates as a whole in the same direction as the head
Importance of Reflex: the reflex orients the body in relation to the head. However, if integration does not occur it will prevent the individual from movement against gravity, proper alignment of the body and the ability to maintain balance
Body Righting Acting on the Body
Normal Age: 6 to 18 months
Test Position: patient is placed in a supine position with the head in midline and the arms and legs extended
Test Stimulus: The head is rotated to one side either actively or passively (or you can move the hips)
Negative Reaction: the body rotates as a whole unit
Positive Reaction: segmental rotation of the trunk between the shoulders and pelvis occurs (shoulders–>trunk–>hips)
Importance of Reflex: This reflex orients the body in relation to the head. However, if integration of this reaction does not occur it will prevent the individual from movement against gravity, proper alignment of the body, and the ability to maintain balance
Generally describe reactions associated with the cortical level.
Reactions at this level are a result of an efficient interaction between the cerebral cortex, basal ganglia, and the cerebellum. This allows the individual to experience bipedal motor skills. (allows people to walk)
Equilibrium Reactions
Equilibrium Reactions
These reactions occur when muscle tone is normalized which enables the individual to adapt to changes in the body’s center of gravity
Negative Reactions: the head and thorax do not right themselves; no equilibrium or protective reactions are elicited
Positive Reaction: righting of the head and thorax occurs, abduction and extension of the arm and leg on the raised side occurs, and protective reactions on the lowered side are elicited
Importance or Reflex: These reactions enable the individual to recover balance and maintain the normal position of the head in space which allows the individual to move against gravity. However, if these reactions are not fully developed it will prevent the individual from movement against gravity, proper alignment of the body, and the inability to maintain balance
Testing Equilibrium Reactions in Sitting
Normal Age : 10-12 months throughout life (can test as early as 6 months)
Test Position: patient is seated on a chair (or in lap while in chair or therapy ball)
Test Stimulus- the patient is pulled or tilted to one side
Testing equilibrium reactions from four point kneeling
(quadruped)
Normal age: 8 months throughout life
Test Position: the patient is placed in quadruped position
Test Stimulus: the patient is pushed to one side
Testing equilibrium reactions from kneel-stand
Normal Age: 15 months throughout life
Test Position: the patient is placed in a kneel-stand position
Test Stimulus: patient is pulled or tilted to one side
What is motor control?
The ability to regulate or direct the mechanisms essential to movement
What does motor control refer to?
- How the central nervous system organizes movement
- How we quantify movement
- The nature of movement
Where is motor control found?
person, task, environment
What is motor learning?
The study of the movement processes associated with practice, such as experience, motivation, reinforcement, motor skill, and developmental progress, that lead to a relatively permanent change in a person’s capability for skilled action
What are the current issues with motor learning?
Role of feedback and types of practice in learning new skills (Random vs Block)
Role of motivation and meaningfulness
What is Motor Development?
The study of how motor behavior changes over the lfiespan
What are the current issues in motor development?
Age-related differences in motor performance due to development and maturation resulting from genetics, body dimensions, environment, motivation, experience, practice and expectations
Develop in varied ways depending on personal and environmental influences
What are some common conditions with motor deficits?
CP, DCD, PDD, Down syndrome, SI disorders, Acquired Brain injuries
What is the typical motor development for a newborn?
- primarily relexive
- prone-physiologic flexion, hands fisted, thumbs in, head turned to one side, wt on face, shoulder and hands
- supine - random movements, more movements in LE
- reciprocal walking movements - stepping relfex
What is the typical motor development for a 1-2 month old?
- Arms moving toward abduction
- less physiologic flexion - increased hip/knee extension, reciprocal kicking
- wt on ulnar border, hand regard - in prone
- increase in joint range - moving out of contraction
- asymmetry of extremities
- hands to mouth, sucks fingers
- becoming more voluntary, one of the very first voluntary movements seen in infants
What is the typical motor development for a 3-5 month old?
- smoother and more purposeful movements
- forearm wt bearing - head bobbing to smooth
- 45-90 degrees head/neck extension
- Head lag PTS - midline and no lag
- Cervical and thoracic spine extension
- props to sit (tripod)
- Head righting, wt. shifts laterally, swimming -in prone will move into labyrinthine reflex
- supported standing with wide base and hands held
- still missing trunk rotation
- Head lag - in supine grab wrists and pull infant into sitting head should be in ext. because of lack of neck control
- **PTS - pull to sit
What is the typical motor development for a 6-8 month old?
Posture against gravity
Protective extension forward - arms extend for protection
Roll supine - side - prone
Pushes into bear/quadruped
Sits with erect spine, trunk rotation key for reaching balance
Tall kneel, creeping, rocking (moving in an out of STNR), pivot prone, curises, hand arches develop via wt shift (become stabilizing force for hand movements), unilateral reach in sit, rakes small objects
*important to see w/b in shoulders and hands –> build shoulder girdle
**Some may begin to crawl at this age. some babies never crawl
What is the typical motor development for a 9-12 month old?
Transitional postures of side sitting, kneeling, 1/2 kneel, pull to stand using UE and standing
Increased lumbar extension S-curve that places head and trunk over the hips
Hands are free to manipulate toys. Begin bimanual dexterity - each hand doing a different task. 3 jaw chuck, pincer grasp
* FM skills take off
** most are beginning to walk. If baby isn’t walking by 15 months –> concern
What is the significance of reflexes?
Involuntary stereotyped response
Early way infant changes distribution of muscle tone
building block for movement
damage to CNS decreases the ability for someone to inhibit the lower level reflexes so they can dominate movement patterns limiting the ability to move smoothly, freely and in a controlled fashion
the key to be able to observe when the lower level reflexes are affecting movement
reflexes contribute to the development of muscle control for mobility and stability
reflexes take infants through movements that possess essential elements for higher level functioning
provide opportunities for interactions with environment
If reflexes persist-called poorly integrated or obligatory
What is considered the foundational knowledge for NDT and the qualitative aspect of movement?
Typical development
Recognizing influence of primitive reflexes
Recognize poor quality of movement that affects higher level skills
What are the Neuro-Developmental Treatment Principles?
NDT techniques can facilitate typical motor patterns while inhibiting atypical patterns
Key points of control (hand placements to influence weight shifting): Give maximal control over movement and influence posture and movement of trunk, shoulder girdle, hip and distal key points of control
Used to manually assist in movement patterns
What are Key Points of Control?
Therapists controls the quality and characteristics of movement while client follows manual cues and moves with assist
Decrease amount of assist as pattern of movement normalizes (so child can feel movement on own)
To assess movement: Move client in/out of postures and movement sequences to evaluate ability to perform occupations and evaluate primary and secondary problems
How and what do you assess for functional movement?
Facilitate trunk movement, equilibrium reactions and protective reactions
Assess: quality of movement, strength, movement control, and effort/flow
What are some NDT intervention strategies suggested?
Assessment of these movement patterns (balance and spontaneous movement) allows identification of movement patterns for handling: increase ROM, facilitate balance, graded control of movement, facilitate rotation and transitional movements
** don’t have to progress developmentally but need to be within reason
What are the principles of treatment for NDT?
Decrease tone
should not be static- move to inhibit tone/postures
weight bearing with mobility - decreases tone, and increases strength
avoid compensation
give time to react for success
break up total patterns with rotation with extension
use key points of control
“just right challenge”
use a variety of patterns
What techniques do you use to change tone in NDT?
gain alignment wt shift w/b rotation change position in space approximation/traction affective changes - social interactions - meaning elongation movement ranges movement rate RIP's level of activity environmental status movement rhythm
What are persistent primitive reflexes and what are the consequences of them?
Due to brain damage and difficulty moving voluntarily
Persistence or reemergence
Particularly ATNR, STNR, and TLR
Delays postural reflexes (equilibrium and protective reactions)
Doesn’t necessarily delay motor milestones (depends on severity of injury)
What is abnormal tone, motor control and force generation?
Hypertonia, hypotonia, spasticity
limited postural reactions, antigravity movements, proximal muscle co-contraction, stability in upright positions
“fixing” - locking body segments to provide stability but blocks mature movement patterns, for example fixing head control by hyperextending neck and elevating shoulders prevents protraction of shoulders from midline play
Hyperreflexia - blocks the development of graded movements
“overflow” (associated reactions) - continuation or excessive overflow decreases precision reactions and may delay protective reactions
Contractures - due to spasticity or abnormal soft tissue changes also disrupt development of postural control
limits of stability - may be more limited on one side causing child to shift center of balance
What are the three components of balance?
vision
proprioception
vestibular
**all developed based on experiences
What is altered sensory function/integration?
Good postural control relies on both intact peripheral pathways and the CNS interpretation of the input
Visual deficits - result in deficits in static and dynamic balance
Vestibular deficits - problems with balance when there is conflicting information
Children with CP or LD show deficits in CNS interpretation of the sensory input and have particular difficulty when there is conflicting info (ex motion sickness)
How is motor response organized?
To respond to a loss of balance a child must activate the appropriate muscle groups with accurate timing and in the correct amplitude
This on set of motor response is delayed in children with Down’s Syndrome and with CP
Child with CP may activate the wrong muscles or the right muscles with poor timing and amplitude
Additionally the child with CP may have poor anticipatory control
*don’t have the feed forward ability to anticipate reactions
What impact does muscle tone have on motor development?
Muscle tone refers to the amount of tension or resistance to movement in a muscle. Muscle tone is what enables us to keep our bodies in a certain position or posture. Changes in muscle tone are what enables us to move. For example, to bend your arm to brush you teeth, you must shorten (increase the tone of ) the biceps muscles on the front of you arm at the same time you are lengthening (reducing the tone of) the triceps muscles on the back of your arm. TO complete a movement smoothly, the tone in all muscle groups involved must be balance. The brain must send messages to each muscle group to actively change its resistance. Abnormal muscle tone is a prominent symptom of cerebral palsy.
Spasticity (increase or “high” muscle tone)
Advantages of spasticity: a) substitues for strenght, allowing standing, walking, gripping b) may improve circulation and prevent DVT and edema c) may reduce the risk of osteoporosis
Disadvantages of spasticity
a) orthopedic deformity, such as hip dislocation, contractures, or scoliosis b) impairment of ADLS c) Impairment of mobility d) skin breakdown secondary to positioning difficulties and shearing pressure e)pain or abnormal sensory feedback f)poor weight gain secondary to high caloric expenditure g)sleep disturbances h)depression secondary to lack of functional independence
Hypotonia (decreased or “low muscle tone) a) floppy “rag doll” b) poor head control c) decreased mobility e) lordosis posture f) difficulty with breathing and speech g)lethargy h)ligament and joint laxity i)poor reflexes
