University of South Australia School of Health Sciences Applied Kinesiology

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University of South AustraliaSchool of Health
SciencesApplied Kinesiology

• Early Development Lecture 7
• Atypical Movement
• Principles of Management
• Liz Pridham 2008

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Children at risk

• Groups of children at risk for atypical movement
• Born prematurely (less than 37 weeks)
• CNS damage eg Cerebral Palsy
• Chromosomal Disorders eg Down syndrome

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ATYPICAL DEVELOPMENT OF MOTOR CONTROL

• Relative to the principles of normal movement
  development
• Atypical movement development can either begin in
  utero, or some time after birth, depending on
  pathology.

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Preterm infants (lt37 weeks gestation)

• Low muscle tone (hypotonicity)
• Greater flexibility ROM around limb joints
• Parts of limb move together (synchrony) gt term ?
  delayed walking
• ? Difficulty with excitation of agonist and
  inhibition of antagonist.
• Term infants loosening of synchrony at 5/12
  allows development of crawling and walking
  (Piek 2006 p. 220)

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Children with CNS damage

• Difficulty with diagnosis
• Early detection can lead to over-identification

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Potential problem signs in first 12 months

• 0-3 m include
• Limited random movements baby feels stiff
• Easy and frequent startle response
• Poor head control with reliance on head neck
  hyperextension
• Problems with feeding, breathing irritability
• 4-8 m
• Hypotonia
• Movement in mass patterns with limited variety
• Asymmetry
• Limited spinal ext.
• Limited visual and reach grasp control
• (Boehme 1990 cited in Piek 2006 p. 241)

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Potential problem signs in first 12 months

• 9-12 m include
• Limited variety of movement
• Poor trunk control and postural responses
• Poor manual skills
• Hypotonicity or hypertonicity
• (Boehme 1990 cited in Piek 2006 p. 241)

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How the movement looks

• Often "get stuck" at movement in sagittal plane.
• Early extension is not balanced by antigravity
  flexion.
• Asymmetry may dominate eg strong ATNR
• Symmetry may dominate eg unable to weight shift
• Rotation is the last component to develop - if at
  all.

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How movement is affected

• Unable to selectively recruit or differentiate
  movements.
• Results in
• a persistence of mass patterns of movement
• the presence of unwanted background movement
• a limited movement repertoire.

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ATYPICAL DEVELOPMENT OF MOTOR CONTROL

• Postural control is only partially achieved, or
  not at all.
• Differences in children with CNS dysfunction
  compared with typical postural responses
• altered timing of muscle activity for postural
  adjustments
• direction of postural adjustments less specific
• less activity in anticipation of voluntary
  movement

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ATYPICAL DEVELOPMENT OF MOTOR CONTROL

• The structure of muscle is dependent on the
  conditions of use therefore
• prolonged ? muscle length results in ? sarcomeres
  and ? extensibility
• lengthened muscles cant generate tension in
  inner range
• skeletal growth can be influenced by abnormal
  muscle forces

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Atypical Gait

• Impairments that can contribute to atypical gait
  patterns include
• abnormal motor control
• spasticity
• loss of range of movement (ROM)
• decreased strength
• loss of sensation
• bony deformity (Stout 2006 p.183)

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Quizz

• At what age would you expect
• Midline orientation to be present
• Independent sitting
• Balance for a few secs. on preferred leg
• Genu valgum to be at its maximum
• Ability to catch a ball (20 cms) between hands

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Answers

• 4 months
• 6-9 months
• 3 years
• 2 ½ - 3 ½ years (3 years)
• 5-6 years

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Impact of impairments associated with Cerebral
Palsy (CP) on gait

• Bony Deformity
• 1. Medial Femoral torsion
• Femur twists and knee points in due to
• ?adductor IR pull (spasticity)
• ? use of extensors and ERs in kicking WB
  (weakness)
• 2. Lateral tibial torsion
• 2º to medial femoral torsion or limited knee
  motion ? dragging of the foot in an externally
  rotated posture for clearance.
• (Stout 2006 p.183)

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Impact of impairments associated with Cerebral
Palsy (CP) on gait (cont.)

• Spasticity inadequate range of motion
• Predominantly the 2-joint muscles (fast-twitch
  and used for force production) affected.
• 1. Plantar-flexion knee extension couple
• Spasticity in gastroc. Doesnt allow forward
  progression of tibia in Loading Response (LR) ?
  knee remains extended.
• 2. Crouched gait (Increased flexion in all LL
  joints.)
• Loss of length in psoas hamstrings with
  weakness in plantar flexors
• The ground reaction force falls posterior to the
  axis of the knee joint ? ?flexion at the knee.
• (Stout 2006 p.185)

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Impact of impairments associated with Cerebral
Palsy (CP) on gait (cont.)

• Spasticity inadequate range of motion
• 3. Limited swing-phase knee motion
• Pre-swing Typically gastroc. provides momentum
  for knee flexion ? ground reaction force behind
  the knee.
• Weak Gastroc ? hip flexors provide momentum to
  clear the foot.
• Swing spasticity in rectus femoris ? lack of
  lengthening for knee flexion
• Compensations include
• Circumduction of swing leg
• Increased hip flexion in swing leg
• Vaulting (rising up on toes of stance leg)
• (Stout 2006 p. 185 186

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Impact of impairments associated with Cerebral
Palsy (CP) on gait (cont.)

• Weakness
• 1. Hip abductor weakness
• uncontrolled pelvic drop on the swing side. To
  keep the COG over BOS trunk is LF over the stance
  limb.
• (Stout 2006 p.186)

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Gait Analysis

• Gait analysis can be used to help determine the
  factors that are contributing to the atypical
  pattern.
• 2Dimensional gait analysis (2DGA) captures the
  sagittal plane but difficult to capture movement
  in the coronal and transverse planes.
• 3Dimensional gait analysis (3DGA) can provide
  information about all three planes of movement
  (more time consuming and expensive)

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Down Syndrome

• Hypotonia and laxity of ligaments
• Slower reaction times
• Weaker voluntary muscle contraction
• Delayed motor development (on average delayed but
  due to large variability some chn with DS can
  achieve motor milestones as expected for
  typically developing chn.

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• Babies with Down syndrome
• Poor antigravity control
• Hypotonia
• Ligament laxity

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Generalised hypotonia
Arthrogryposis
Spinal Muscular Atrophy
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Quizz

• How do children
• Get up from the floor between 1 2 years of age?
• Go up and come down stairs at 3 years of age?
• Indicate an object at 10 12 months?
• At what age would expect
• Children to squat to play?
• Lateral head control to develop?

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Answers

• Push up thro both legs
• Up 1 foot/step down 2 feet /step
• Pointing using
• index finger only
• 13 15 months
• 4 - 5 months

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Principles of Management Assessment

• Occurs at the levels of
• participation (what life roles is the child
  engaging in and which are restricted)
• activity (what can the child do functionally and
  what is limited related to age expectations)
• impairment (what at the level of body structure
  and function is limiting the activity
  performance) (WHO 2002)

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Children's Activity/Function

• Expected skills will be dependent on child's age.
  In the younger child include
• sitting
• rolling
• crawling
• pulling to stand
• cruising
• walking

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Children's Activity/Function

• Further skill development includes
• running
• jumping
• hopping
• galloping
• skipping
• Object control
• roll, throw, catch, strike kick a ball
• fine manipulation and tool use

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Impairments

• Impairments at the level of body structure and
  function include
• bony absence malalignment
• joint incongruity
• ligament laxity
• muscle weakness poor endurance, ? or ? length,
  ? or ? tone
• poor postural control

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Impairments (cont.)

• Impairments at the level of body structure and
  function include
• poor coordination
• poor hand-eye foot-eye coordination
• reduced grading sequencing of movement
• reduced motor planning

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Impairments (cont.)

• Impairments at the level of body structure and
  function include
• poor vision
• poor proprioception
• poor vestibular function
• reduced cognitive functioning

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Aims of Intervention

• Focus for an improved outcome can be to change
  the
• childs skills and impairments
• the task
• the environment

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Strategies

• Positioning for function. Provide support so that
  optimal posture enables the action to be
  performed
• Example of support could be a rolled towel under
  the trunk in prone to keep arms forward and
  reduce the impact of gravity or postural seating
  to provide stability for UL function and eating
  and drinking.
• Use of orthotics. Supports the body parts in the
  optimal alignment to enable function
• Example of an orthotic is a hinged Ankle Foot
  Orthosis (AFO) allows DF but not PF

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Strategies

• Increased sensory input to elicit a response or
  compensate for poor responses in one system
• Example could be using sound toys to encourage
  head turning in a child with a vision impairment.
• Use of stamping to increase proprioceptive input
  thro LL

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Strategies

• Strengthening increase in localised strength or
  more general endurance in muscles
• increase range of motion in joints using passive
  and/or active movements.
• increase length of shortened muscles with passive
  or active stretch eg could manually stretch
  hamstrings or could get child doing bear walks
• reduce dynamic tone using stretching/serial
  casting/ Botulinum Toxin A (Botox)

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Strategies

• Motor learning.
• may need to break down or simplify the task
• Eg Jumping
• Teach landing with bent knees
• then focus on increasing propulsion by jumping
  over a height
• then focus on assistive arm movements.

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Strategies

• Motor learning.
• repetition and practice using play as a motivator
  eg hopscotch is more interesting than doing 10
  hops on 1 foot 3 X a day.
• simple to more complex environment eg work on
  ball skills before introduce child to netball or
  soccer where there are a lot more variables to
  manage

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Strategies

• More specific strategies
• Biofeedback
• Functional Electrical Stimulation
• Ultrasound
• Care should be taken with any electro-physical
  agents as children are not reliable reporters of
  what they feel.

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Strategies

• More general strengthening and balance as well as
  social aspects and parent support if undertaken
  in a group
• Aquatic physiotherapy especially the Halliwick
  approach
• Hippotherapy (managed horseriding)

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Intervention with Children

• Key factors
• Involve parents as key decision makers
• Find out what children are motivated to improve
  in (school age)
• Use your voice to motivate and give feedback
• Pitch activities at the optimum level of
  challenge
• Help the child to reflect on their success or
  what they need to improve
• Identify opportunities with parents and/or child
  for practice/learning at home/community

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References Atypical Movement

• Campbell SK (2006) The child's development of
  functional movement (3rd ed). In Campbell SK,
  Vander Linden D Palisano R (Eds.) Physical
  therapy for children. Philadelphia WB Saunders
  Co. pp 33-76
• Bradley NS Westcott SL (2006) Motor Control
  Developmental aspects of motor control in skill
  acquisition. In Campbell SK , Vander Linden D
  Palisano R (Eds.) Physical therapy for children
  (3rd ed). Philadelphia WB Saunders Co. pp
  77-130.
• Damiano DL (1993) Reviewing muscle
  cocontraction Is it a developmental,
  pathological, or motor control issue? Physical
  Occupational Therapy in Pediatrics 12 3-20.

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References Atypical Movement

• Piek J (2006) Infant Motor Development. Human
  Kinetics, Australia
• Shepherd RB (1995) Physiotherapy in paediatrics
  (3rd ed). Oxford Butterworth-Heinemann. pp
  10-12, 98-100.
• Stout, JL (2006) Gait Development and
  analysis. In Campbell SK , Vander Linden D
  Palisano R (Eds.) Physical therapy for children
  (3rd ed). Philadelphia WB Saunders Co. pp161-190

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References Principles of Management

• Burns Y (1996) Principles of Physiotherapy
  Management. In Burns Y McDonald J (Eds.),
  Physiotherapy and the Growing Child. WB Saunders,
  London. pp 123-130
• Shumway Cook Woollacott (2000) Clinical
  management of the patient with a mobility
  disorder. In A Shumway-Cook M Woollacott. (Eds)
  Motor Control Theory and Applications (2nd ed.).
  Lippincott, Williams Wilkins, Philadelphia pp
  397-445