Early Detection of Motor Problems and Delays: The Pathways Awareness Foundation

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Early Detection of Motor Problems and Delays
The Pathways Awareness Foundation

• Michael N. Nelson, Ph.D.
• Member, Medical Round Table
• Pathways Awareness Foundation
• 150 North Michigan Ave., Suite 2100
• Chicago, IL 60601
• September 28, 2007

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Pathways Awareness Foundation Medical Round Table
(est. 1985)

• Co-Chairmen H. Garry Gardner, M.D., FAAP, John
  F. Sarwark, M.D., FAAP, FAACPDM
• M.D.sDeborah Gaebler-Spira, Fredric Leary, Jr.,
  Karen R. Judy, Michael E. Msall, Lori Walsh
• Ph.D.sSuzann K. Campbell, Michael N. Nelson,
  Katie Silverman
• Nurses/TherapistsGay Girolami, Amy Becker
  Manion, Rosemary White-Traut, DNSc
• Parents/OfficersAnita Bujnowski, Margaret C.
  Daley, Shirley Welsh Ryan

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Pathways Resources for Parents

• Hotline [phone], TTY 800-326-8154)
• Pathways Center, Glenview, IL 60026
• Website pathwayscenter.org
• Email friends_at_pathwaysawareness.org
• Brochure Assure the Best for your Babys
  Physical Development with mass distribution
• Continuing education, films
• Special events and summer programs

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Pathways Resources for Professionals and Students

• Training materials (slides, films)
• Continuing education programs
• Provision of guest speakers
• Inclusion of Pathways materials in medical school
  curricula
• American Academy of Pediatrics endorsement
• National Association of Pediatric Nurse
  Practitioners endorsement

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Why Worry About Motor Function?

• The brain is a
• motor organ
• Neuroscience Reviews

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Motor function is a marker of risk because of
the lack of redundancy in motor pathways in
mammals
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Development in the first postnatal year is
largely sensory-motor in nature, suggesting that
wide variability in performance may reflect
individual differences in motor capabilities
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Neonatal General Movements An Early Predictor
for Neurodevelopmental Outcome in Infants with
Intrauterine Growth Retardation

• Zuk, L., Harel, S., Leitner, Y., Fattal-Valevski,
  A. (2004) Journal of Child Neurology, 19, 14-18
• (fewer normal general movements on videotape)

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Construct validity of the test of infant motor
performance (TIMP)

• Campbell, S.K., Kolobe, T.H., Osten, E.T., Lenke,
  M., Girolami, G.L. Physical Therapy, 1995,
  75(7), 585-596

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Campbell et al. paper judged the best paper
published in the journal Physical Therapy in 1995
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The TIMP is a test of functional motor behavior
in infants for use by physical therapists,
occupational therapists, and other health
professionals in special care nurseries and early
intervention or diagnostic follow-up settings.
The TIMP can diagnose motor developmental delay
from 34 weeks postconceptional age through 4
months post term based on age standards developed
from a sample of 990 U.S. infants of all
races/ethnicities
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Comparison of test of infant motor performance
(TIMP) item responses among children with
cerebral palsy, developmental delay, and typical
development

• Barbosa, V.M, Campbell, S.K., Smith, E.,
  Berbaum, M. American Journal of Occupational
  Therapy, 2005, 59(4), 446-456

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Barbosa, Campbell, Smith, Berbaum
(2005)Items discriminating among the three
outcome groups included hand to mouth, neck
control, rolling, and pull to sit items,
particularly at ages term, 9 weeks, and 12-13
weeks corrected age. Children with CP presented
"advanced" performance in items using extension
patterns and slow development or regression in
items requiring antigravity and balanced used of
flexion-extension patterns of muscle activity.
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Human development is not linear, but occurs in
stages

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Development From Birth to 36 Years of Age
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The Development of Children (5th
edition)

• Cole, M., Cole, S. R., Lightfoot, T. New York
  Worth Publishers, 2004

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Peri-Postnatal Neurodevelopmental Stages

• 38-42 weeks--birth
• 2-3 months--cortical control
• 6-8 months--perceptual constancies
• 11-13 months--frontal lobe connections
• 16-18 months--verbal thought
• 25-30 months--verbal fluency
• 4-7 years--school readiness, hemispheric dominance

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Neonatal Brain Growth Spurt
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Neurodevelopmental Stage Transition, Birth (40
weeks)

• Temporary increase of irritability
• Neurological changes, tremor, sun-setting of
  eyes, changes in asymmetry
• Maturation of reflexes
• Improved mobility of visual attention with
  preference for familiar stimuli and rejection of
  novelty (looking away)
• Improved response to higher auditory frequency,
  preference for familiar sounds

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Postnatal Neurodevelopmental Stages

• 2-3 months--cortical control
• 6-8 months--perceptual constancies
• 11-13 months--frontal lobe connections
• 16-18 months--verbal thought
• 25-30 months--verbal fluency
• 4-7 years--school readiness, hemispheric dominance

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2-3 Month Neurodevelopmental Transition
Neonatal Period Stage Transition Mature
Infant Behavior
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Neurodevelopmental Stage Transition, 6 weeks to 3
months

• Corticospinal inhibition of reflexes
• Hands open, reaching/grasping for toys
• Improved vision, preference for novel over
  familiar stimuli, likes complexity
• Social smiling with preference for family
• Mobility of attention, localizes sound
• Expressive cooing to reveal emotions
• Development of antigravity (head and body)
  righting and supporting reactions

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Emerging Neuromotor capabilities, 6 wks to 3 mos.

• Inhibition of neonatal reflexes
• Head in midline in supine
• Hands open, reaching/grasping for toys
• Full vertical head elevation in prone with
  extended arms
• Development of antigravity (head and body)
  righting reactions

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Early Recognition of Infants at High Risk for
Cerebral Palsy Examination at Age 4 Months

• Ellenberg, J.H., Nelson, K.B. Developmental
  Medicine Child Neurology, 1981, 23, 705-716

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Early Infant Assessment Redefined

• 150 N. Michigan Ave Suite 2100 Chicago, IL
  60601
• 800-955-2445 friends_at_pathwaysawareness.org
• www.pathwaysawareness.org

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Film Early Infant Assessment--Redefined
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AN EIGHT-STEP INFANT ASSESSMENT PROCESS 1.
SUPINE 2. SIDELYING 3. PRONE 4. PULL TO SIT 5.
SITTING 6. STANDING 7. HORIZONTAL
SUSPENSION 8. PROTECTIVE EXTENSION
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SUPINE

• Visual Tracking of 1800
• Head in Midline
• Reach and Grasp
• Anti-Gravity Movement
• Pelvic Lifting

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SIDELYING

• Head in Midline
• Muscle Balance
• Muscle Activation
• Weight Shifting
• Lateral Righting

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PRONE

• Head/Trunk Lifting
• Forward Reach
• Hip Extension
• Lateral Weight Shifting

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PULL TO SIT

• Leads with Head
• Forward Flexion of Head
• Shoulder Stability
• Abdominal Muscle Activity

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SITTING

• Head in Midline
• Actively Leans Forward
• Reach and Grasp
• Good Back Extension
• Upright Sitting

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STANDING

• Postural Alignment
• Free Movement of Arms
• Hip Extension
• Leg Mobility
• Weight Bearing on Flat Feet

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HORIZONTAL SUSPENSION

• Anti-Gravity Alignment/Extension
• Variety of Movement

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PROTECTIVE EXTENSION

• Head in Midline
• Forward Movement of Arms
• Anti-Gravity Alignment

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Emerging Neuromotor capabilities, 6-8 months

• Rolls from supine to prone by 6-7 mos.
• Crawls on hands and knees by 7-8 mos.
• Pulls-to-stand by 8-9 mos.
• Cruises next to furniture by 9-10 mos.
• Pincer grasp by 9-10 months

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Postnatal Neurodevelopmental Stages

• 2-3 months--cortical control
• 6-8 months--perceptual constancies
• 11-13 months--frontal lobe connections, walking
  and talking
• 16-18 months--verbal thought
• 25-30 months--verbal fluency
• 4-7 years--school readiness, hemispheric dominance

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Conclusions

• Evaluate carefully through the first 6 months
• Observe the quality of motor behavior and range
  of movement
• Document and quantify all asymmetries, no matter
  how trivial they may seem (TIMP?)
• Direct observation of key behaviors and
  capabilities in 8 standard test situations is
  clearly diagnostic by 6 months of age
• Recommend appropriate intervention(s) in
  collaboration with the parents