Early Identification and Treatment Techniques in Babies With

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Early Identification and

Treatment For Babies with High

Risk of Neurological Impairment

By


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Aim

To understand the importance of primitivereflex in early identification and to know

the intervention techniques


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Objectives

To Know the Incidence level.

To know the Developmental Profile. To know about Primitive reflexes.

To know the Pointers to CNS Insult.

To understand the Treatment principles.


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Incidence

Children with neurological impairment is not completelypreventable as in other childhood diseases likePoliomyelitis, Smallpox etc.

The incidence of Cerebral Palsy in undeveloped areas ofthe world, where infant mortality is very high, is the sameas in northern Europe, where infant mortality is thelowest.

It also explains why modern obstetrical care, includingmonitoring and a high rate of Cesarian section, haslowered infant mortality rates but not the incidence ofcerebral palsy.

This gives a message that preventing completely is likelynot possible.


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Incidence

One important reason again goes to moderndevelopments in Medicine, where prematurebabies and high risk babies are now able tosurvive, with some babies compromised withtheir nervous system.

Also it throws light on the tunnel vision ofhypoxic brain damage as a primary reason forbrain injury.

There are many genetic causes stillundiscovered.


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Neuroanatomi-

cal structures

Postural Reflex

Development

Motor

Development

Cortex EquilibriumReactions

Voluntary Control

Midbrain Righting

Reactions

Excitatory &

Inhibitory Control

Brainstem/

Spinal Cord

Primitive

Reflexes

Stretch Reflexes


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The Developmental Profile

Sophisticated Cortex

Primitive Cortex

Early Cortex Initial Cortex

Mid Brain

Pons Medulla and spinal Cord


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Sophisticated cortex Using a leg in a skilled

role which is consistent

with the dominant hemi

Primitive Cortex Walking and running incross patterns

Early Cortex Walking with arms freed

from the primary

balance role

Initial Cortex Walking with arms used

in a primary balance role


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Midbrain Creeping on hands and

knees (cross pattern)

Pons Crawling in the prone

position(cross pattern)

Medulla and cord Movements controlled

by primitive reflexes


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Role of Primitive Reflex in

Development The above profile tells us that when the baby is born the

CNS is not fully matured. The tone, posture andmovements are under the unopposed control of thelower centers of the CNS.

The baby is influenced by primitive/postural reflexes. The body responds mechanically and automatically to a

no. of influences, such as head or body position.

The baby at birth is motorically at a primitive, crude level,a reflex level.

The movements are automatic with no component ofvoluntary control or meaningful direction.


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Early Identification

Can be made Clinically examining the primitive reflexes

Going by the development of the Baby

With C.T (computerized Tomography) Scans and

M.R.I studies.

All the above has to be matched with the

prenatal and birth histroy.


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The evaluation of pathological motordevelopment had remained the source ofdiagnosis in the early 80s.

A standardized classification for the varioussymptoms and neuromuscular reactivity had notbeen available.

It was Vojta who developed a standardized

diagnostic procedure through which it is possibleto detect the development of neurologicalimpairment in early stages of life.


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Early Identification-VOJTA BASIS

The common basis for classification,according to vojta, is the ability of thecentral nervous system to react

appropriately to postural changes. For this purposes, vojta has chosen 7

postural reflexes that inform us about thequality and extend of neurologicaldevelopment from the newborn period untilupright coordinated walking is possible:


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Early Identification-Vojtas Reaction

The traction reaction

The landau reaction

The axillary suspension reaction

The vojtas side-tilt reaction

The collis horizontal suspension reaction

The peipers and isberts verticalsuspension reaction

The collis vertical suspension reaction


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One may not diagnose cerebral palsy in the first6 months of life. However with the help ofpostural reflexes, it is possible to diagnose areduction of the ability to regulate automatically

the bodys position in space. Vojta has created a diagnostic category for this

inability: disturbance of central coordination.

This is not an etiological diagnosis.

Neurological impairment may develop from adisturbance of central coordination, but notnecessarily.


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It is always noted the same stereotypicalabnormal patterns in a case of disturbedcentral coordination.

Such pattern are similar to the fixedpathological patterns of fully developedchildren with cerebral palsy.

Eg. Rigid extension or rigid flexion of thearms with retraction of shoulders andclenched fists;


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Opisthotonos or extreme hypotonicity of

the trunk.

Rigid extension combined with adduction

of the legs.


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Baby with Normal patterns and

Stereotypical patterns


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Grading a disturbance of central

coordination has proven very important for

clinical practice.

The gradation is based on the thesis that

the more the brains coordination ability is

disturbed, the greater the number of

abnormal postural reactions will be.


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Pointers to CNS Insult

Grading

Central coordination

Mildest 1,2 or 3

Reactions abnormal

Mild 4 0r 5 reactions

abnormal

Moderate 6 or 7

Reactions abnormal

Severe- more than seven

Reactions abnormal


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Pointers to CNS Insult

This understanding will help us to know how to

identify a new born baby with high risk.

Further as their basic function is survival, if they

are suppressed or absent it is a pointer to aninsult to the CNS.

These reflexes has to be integrated at a certain

period of time, if they are present beyond the

normal time it again is a pointer to insult to the

CNS.


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Early Intervention

Early intervention aims at giving normal sensory-

motor feedback for normal development.

Persistence of primitive reflexes blocks the

development of higher level reactions. So early intervention techniques focuses on

inhibiting abnormal reflexes and facilitating

normal reactions.

Which can be done with the activities of daily

living.


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Early Intervention Techniques

Positioning Nest Positioning

Hammock

Handling Lifting Carrying

Feeding

Dressing

Sensori-motor Intervention Lap Treatment

Vestibular Stimulation


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Positioning

Proper Positioning of the child is essential

to ensure the appropriate environment

which enhances the psychomotor and

sensori-motor development.

The child can be positioned in supine,

prone and side lying.


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Positioning Goals

FLEXION

To facilitate midline orientation & develop bodyimage.

To endorse ventral muscle activity. Facilitate stability in longitudinal axis of the body.

Enable and stimulate activity of diaphragm.

Facilitate respiration and feeding reactions.

Promote spontaneous activity of the child and togive him the chance to practice and strengthenphysiological postural and movement patterns.


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Positioning in different positions

In Supine, a nest is build with the help of atowel or a u-shaped pillows, the baby can

safely and comfortably be brought into

flexion. The child feels safe as she issafely surrounded by comfortable material.

She can feel her body and relate to her

dimensions.


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Positioning in Side lying

In side lying, the pillow/towel snuggleslike a half moon against the back, between

legs and against the chest. This way, the

child experiences containment and thussecurity and stabilization in a flexed

position.


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Positioning in Prone Lying

In prone a towel is rolled and placed under

the sternum to avoid retraction of the arms

and to offer the possibility of a slight

weight-bearing on the forearms.


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HANDLING

Handling is the carry-over from treatmentto everyday life. While being handled i.e,

being dressed, undressed, picked up,carried, fed etc., the child has to adjust tobeing moved.

Depending on the degree of theimpairment ,the child can either participateor is totally dependent on the caretaker. .


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Handling

Handling will have a direct influence on

tone and movement. Hence ,it is crucial

that handling is related to treatment;

To facilitate active and normal participation.

To inhibit abnormal reactions and responses tobeing handled.


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Child carried with minimal support


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Promoting Sitting with Head in

Midline


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SENSORIMOTOR

INTERVENTION

The foremost goals of sensorimotor intervention

are to help the child deal with mass of different,

strange and often unpleasant, if not frighteningstimuli.

To develop the best possible intervention

between child and parents/ caregivers as well as

to offer the opportunity of experiencing normal

postural and movement patterns.


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SENSORIMOTOR

INTERVENTION

The aim is to achieve a calm and alert state to

let the child experience normal movement as

well as visual and auditory interaction.

This normal movements, for ex, consists ofhand-hand/ hand-mouth contact, free movement

of the limbs and positioning of the head and

trunk in midline.

This can be achieved either on the lap or on the

floor.


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Lap Treatment


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Promoting Midline Activities on the

Floor


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VESTIBULAR STIMULATION

(ROCKING)

Abnormalities of movement and behaviour may

be positively influenced through graded

vestibular stimulation. When the child is put intoa towel, with the limbs in mid position, flexion

and H/H, H/M co-ordination are promoted whilst

jittery and unorganized movements are inhibited.

This vestibular stimulation can be done in a

towel or in hands of the therapist or caregivers.


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Vestibular Stimulation


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Carry-over

Carry over of treatment is very important in

early intervention, which can be achieved

only by involving parents or caregivers in

therapy.

Involving Parents in Therapy


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Involving Parents in TherapyChild Walking Independently in a

Parallel Bar


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Child transferring from the Balance

Board to a Stool


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Conclusion

Since Early Intervention is Very important

for babies with high risk for neurological

impairment, its very important to identify

these babies as early as possible, tomaximize their potential to the maximum.


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Early Identification and Treatment Techniques in Babies With

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