1 2009Haynes, Ritchie, Franjoine, McElroy Aspects of Typical Development Margo Prim Haynes, PT, DPT, MS, PCS Jan McElroy, PT, MA, PCS Mary Rose Franjoine, PT, DPT, MS, PCS Gail Rickie, OTR/L

2 2009Haynes, Ritchie, Franjoine, McElroy Organization Functional Activities (Behaviors) Control of posture and movement Status of individual systems

3 2009Haynes, Ritchie, Franjoine, McElroy NDT Enablement Classification Model of Health and Disability DimensionFunctional DomainDisability Domain A. Body structure & functions Structural & functional integrity Impairments A.Primary B.Secondary B. Motor functionsEffective posture & movement Ineffective posture & movement C. Individual functionsFunctional activitiesFunctional activity limitations D. Social functionsParticipationParticipation restriction + Domains - Dimensions From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

4 2009Haynes, Ritchie, Franjoine, McElroy Newborn

5 2009Haynes, Ritchie, Franjoine, McElroy Newborn: F unctional Activities (Behaviors) Breathes on his own Turns head to clear airway Finds food if it’s close Eats and eliminates Attempts to sooth self Establishes bond with parents Uses voice to communicate essential needs

6 2009Haynes, Ritchie, Franjoine, McElroy Baby Pictures!

7 2009Haynes, Ritchie, Franjoine, McElroy Newborn: Posture and Movement Bias toward flexion in the limbs Weight shifts forward toward the face Lower extremities free to move* Phasic burst of extension First attempt to control extension is in cervical spine

8 2009Haynes, Ritchie, Franjoine, McElroy Baby Pictures

9 2009Haynes, Ritchie, Franjoine, McElroy Posture and Movement : Newborn Doesn’t lay completely on back in supine – rounded spine Alignment of rib cage & shoulder complex is elevated allows for hand to mouth activities Hand variety* Pull to sit:

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Newborn: Neuro-motor system Stiffness ↑, cannot grade changes Apparent bias for flexion Muscle activation is concentric phasic bursts Under-damped – Clonus & Tremors

Haynes, Ritchie, Franjoine, McElroy New Born: Musculoskeletal Muscles of flexion in a shortened state First efforts of cervical extension start to elongate anterior neck muscles No strength above fair ‘-’ (i.e. cannot move through range against gravity)

Haynes, Ritchie, Franjoine, McElroy New Born: Sensory Proprioception –More comfortable in flexed position –Deep pressure to oral region

Haynes, Ritchie, Franjoine, McElroy New Born: Sensory Vestibular –Semi-circular canals are functional –Receives input from head movements

Haynes, Ritchie, Franjoine, McElroy Tactile Hyper-responsive to tactile input…if overwhelmed will shut down More adaptive to deep pressure…especially in flexion (i.e. swaddling) New Born Sensory

Haynes, Ritchie, Franjoine, McElroy Newborn: Sensory Vision –Focal length is about 7” –Monocular (…receives info from one eye at a time) Auditory –Alerts to sounds –Can be easily overwhelmed Olfactory/taste –Discriminates olfactory input…finds mom by smell –Taste preferences…prefers breast milk

Haynes, Ritchie, Franjoine, McElroy Newborn: Respiratory Belly breather –Has no resistance to diaphragm pulling down Very rapid…over 100 cycles per minute Very irregular and can be easily disrupted Oral structures promote the production of “ma” when distressed

Haynes, Ritchie, Franjoine, McElroy Newborn: Cardiovascular… Rapid heart beat… bpm Can be irregular Murmurs are common Immature distal system…cold extremities

Haynes, Ritchie, Franjoine, McElroy One – Two Months

Haynes, Ritchie, Franjoine, McElroy One to two months: F unctional Activities (Behaviors) Lifts head higher Holds head up when supported in upright Brings mouth to hand to soothe self Suckles food Engages others with facial expressions

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Posture and movement : 1-2 M Age of (loss of physiological flexion): –Hypotonia –Asymmetry* –Disorganization Active movements in greater ranges

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Posture and Movement: 1-2 M Efforts to lift head results in oral cavity opening up Begin coordinating swallow with breathing Sucking pads absorbing…pattern changes to suckle –Tongue moves forward/backward and up/down with jaw –Starts to leak milk at corners of lips

Haynes, Ritchie, Franjoine, McElroy Posture and movement: 1-2 M Head elevates to 45º with extension through thoracic spine (end of 2 months) Hips positioned in flexion, abduction & external rotation Lateral borders of feet on surface (end of 2 months) Supine & Prone: Asymmetrical postures Pull to sit: “Increased head lag” Astasia Abasia

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Posture and Movement: 1-2 M Head control changes with ability to lift head off adult’s shoulder: in supported sitting not have stability Shoulder girdle remains elevated Forearms accept partial body weight as does the ulnar border of the hand Involuntary grasp and release Awareness of object in hand ↑ by end of 2 months

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy One –Two Months Neuromuscular System Musculoskeletal System Sensory System Respiratory System Circulatory System

Haynes, Ritchie, Franjoine, McElroy Video Clip

Haynes, Ritchie, Franjoine, McElroy Neuromotor system: 1-2 m Decreased control/coordination of levels of stiffness Inefficient controlled balance of flexion and extension Phasic bursts of extension throughout body Brief sustained cervical extension Extraneous movement observed Synergy repertoire expands to include asymmetrical patterns

Haynes, Ritchie, Franjoine, McElroy Musculoskeletal: 1-2 M Greater ranges of movement in cervical spine Elongation of SCM, Scalenes and infra-/supra- hyoids Posterior weight shifts start to open anterior chest wall

Haynes, Ritchie, Franjoine, McElroy Sensory: 1 – 2 M Great variability in child’s ability to maintain homeostasis Visual –Focal length increases to 10” –Acuity is 20/800 to 20/200 –Dramatic increase in activity in the visual cortex

Haynes, Ritchie, Franjoine, McElroy Sensory: 1-2 M Auditory –Greater discrimination of auditory stimuli –Improved localization –Will pause to listen for responses Tactile: –Less sensitive to light touch

Haynes, Ritchie, Franjoine, McElroy Respiratory: 1-2 M Movement of head and weight on chest leads to greater space between sternum and humerus No activity of rib musculature yet Respiratory pattern may look less stable –Paradoxical breathing Will start producing sounds with movement…”pumps out” the sound

Haynes, Ritchie, Franjoine, McElroy Cardiovascular System: 1-2 M Heart rate is down to about bpm More stable pattern Distal system has matured…extremities not as cold or discolored

Haynes, Ritchie, Franjoine, McElroy

Haynes, Ritchie, Franjoine, McElroy Three – Five Months

Haynes, Ritchie, Franjoine, McElroy Functional Behaviors: 3-5 M Observes the world in prone, supine and supported sitting Rolls from stomach to back –Accidental (4 months) to controlled (5 months) Rolls from back to stomach (5 months) Grasps toys with increasing refinement Hands to midline to come toward the bottle More successful soothing self Communicates joy and fun with sounds…experiments with sounds for play

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Posture and Movement: 3-5 M Age of Symmetry and midline orientation –3- 5 months –5 months control developed : beginning to develop asymmetrical control Has active downward gaze with head up Lateral weight shift –3 months…immature –4 months…gets elongation on weight bear side –extension into lumbar spine –4-5 months ….Elongation, with higher elevation leads to rolling from prone to supine –5 months… Rolling supine to prone

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Posture and Movement: 3-5 M Head in midline Flexion, abduction and external rotation of LE’s –Prepares feet for weight bearing Antigravity flexion in supine develops –4-6 months: –plays with legs… reaching to knees, ankles and feet

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Posture and Movement: 3-5 M Side-lying play develops –4 months: flexion/extension balanced to allow side-lying –5 months: play in side-lying

Haynes, Ritchie, Franjoine, McElroy Posture and Movement: 3-5 M Sitting skills emerging: Progress toward independent sit –4 months… Sit with extension to T6-T8 –4 months…Scapular adduction to reinforce upper body antigravity activity in supported sit –5 months …. Using UE support ….getting ready to let go!

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Posture and Movement: 3-5 M Pull to sit –3 months…head control –4 months…UE assist Fully active in pull to sit (end months –No head lag throughout transition –Upper extremity assist –Active abdominals –Lower extremity preparation

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Posture and Movement: 3-5 M Stand with hips flexed behind shoulders Significant change in structural alignment of oral mechanism at 4 months

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Three - Five Months: Systems Neuromuscular System Musculoskeletal System Sensory System Respiratory System Circulatory System

Haynes, Ritchie, Franjoine, McElroy Video

Haynes, Ritchie, Franjoine, McElroy Neuromotor system : 3-5 M Coactivation in C & T spine segments allows ↑ symmetry Opposing forces facilitate increased activation flexion/extension Synergy explosion –Coactivation yields elongation of WB side and axial rotation of upper body –↑ flexion/extension includes activation of serratus –Allows for EROT of shoulder and dissociation between shoulders Graded control of stiffness Increased damping

Haynes, Ritchie, Franjoine, McElroy Musculoskeletal : 3-5 months Increased extension into lumbar spine elongates upper abdominals, hip flexors, latissimus and intercostals –Rolling to sidelye elongates latissimus dorsi and rotator cuff –Thoracic rotation with increased sternal/clavicular mobility elongates intercostals Tongue base musculature elongated F+ to G- upper body and shoulder girdle strength Antigravity pectoral muscles Antigravity cervical flexion at end range Slight active elbow flexion

Haynes, Ritchie, Franjoine, McElroy Sensory : 3–5 months Proprioception –Deep pressure into abdomen, upper extremities and anterior thighs 3 month…forearm/ulnar border allows for increased grasp and discrimination Vestibular –Lateral weight shifts and rolling increases awareness of movements in diagonal planes Tactile –Light touch to mouth, chest, hand-hand, and foot- foot –Tactile discrimination…ticklish

Haynes, Ritchie, Franjoine, McElroy Sensory: 3-5 M Vision –Downward visual gaze –Distance vision across room –Can follow another’s line of vision Emergence of mutual engagement Auditory –Discriminates pitch and intensity…understands power of voice –Looks for speaker

Haynes, Ritchie, Franjoine, McElroy Respiratory System: 3-5 M Rib cage equals one-half of the trunk Activation of abdominals resists the diaphragm –Increased depth of inhalation and longer voice production Can breathe through mouth as well as nose Synchrony of respiration is not disrupted by movement Voicing still derives from moving body –Moves body intentionally to produce voice Expansion of the chest (not from intercostal activity); belly breathing still predominates

Haynes, Ritchie, Franjoine, McElroy Cardiovascular: 3-5 M Cardio –Increased heart size…decreased heart rate Skin –Changes in oral mechanism increases drooling…more “rashy”

Haynes, Ritchie, Franjoine, McElroy Questions anyone?

61 Six Months

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Posture and Movement: 6 M Prone weight shift is more caudal Full elongation of trunk yield dissociation of LE’s Turns head and reaches out to side –More active scapula and increase palmar input –Supports with one hand while manipulating with other Active rolling with LE dissociation

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Six Months: Functional Behaviors (Activities) Props in prone on extended elbows Plays in prone…entertains self Rolls back and forth Independent Sitting Sustains side lying Improved UE control for reaching Complete pull to sit Emerging object appropriate schema Starting to eat solids Starting to drink from cup Babbles and starting to imitate

Haynes, Ritchie, Franjoine, McElroy Posture and Movement: 6 M Holds antigravity flexion in supine –Plays with legs…reaches to knees, ankles, feet –5 months…shoulders off surface –6 months…pelvis of surface Fully active in pull to sit –No head lag throughout transition –Upper extremity assist –Active abdominals –Lower extremity preparation

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Posture and Movement - 6 months Progression toward independent sit –5 month…using UE support –6 month…active gluteals allow stable sit without support Active oral exploration (third hand) –Munching assists with eruption of teeth Stand with support…initiates bouncing

Haynes, Ritchie, Franjoine, McElroy Baby Pictures

Haynes, Ritchie, Franjoine, McElroy Video

Haynes, Ritchie, Franjoine, McElroy Neuromotor System: 6 M Control of extension progresses past hips Increases isolated control to initiate, sustain and terminate muscle activation in UE’s Control of shift between co-activation and reciprocal inhibition progresses to LE’s, allowing for bouncing in stance Control of flexion in trunk to counterbalance extension allows for rotation Prone weight shifting facilitates dissociation of the LE’s Improved gradation of stiffness

Haynes, Ritchie, Franjoine, McElroy Musculoskeletal System: 6 M Quadratus lumborum, gluteus medius and tensor fascia lata elongated from weight shifting through the pelvis Full ROM present at hips, but hip flexors are still tight Lengthening quadriceps and hamstrings Elongation of thenar eminence Muscles of neck, trunk and hip flexors/extensors are at least of F strength Oral exploration yields increased range of lips/cheeks musculature

Haynes, Ritchie, Franjoine, McElroy Sensory System: 6 M Proprioception –Deep pressure in lateral trunk, distal segments –Improved kinesthetic awareness…doesn’t need to watch hand when reaching Vestibular –Vestibular stimulation strong from rolling and bouncing –Increased desire to be upright…resists laying down –Body begins to respond in anticipation of falling

Haynes, Ritchie, Franjoine, McElroy Sensory System: 6 M Vision –Orientation changes because of sitting –Eyes direct hands for reaching –Dissociates eye-head movements –Attends to small objects –Looks for fallen objects Auditory –Improved discrimination…recognizes name –Can pin-point mom’s voice from group –Engages in familiar auditory games

Haynes, Ritchie, Franjoine, McElroy Respiratory System: 6 M Intercostals participate in breathing Increased tidal volume…decreased rate down to 60 bpm Able to increase force of exhalation…allows for screaming and squealing Can interrupt breathing to take sequential swallows Can use breath holding for postural control

Haynes, Ritchie, Franjoine, McElroy Cardiovascular System: 6 M Cardiovascular –Continues to develop Gastrointestinal –Solid foods frequently introduced…system is learning to adapt to varied nutritional sources Perception/memory/cognition –Evolving object permanence –Learning from mistakes…problem solving new motor strategies

Haynes, Ritchie, Franjoine, McElroy Here come our Babies!!