McElroy, Haynes, & Franjoine 2009

M R Franjoine & M P Haynes 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 functions Functional activitiesFunctional activity limitations D. Social functionsParticipationParticipation restriction + Domains - Dimensions From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

McElroy, Haynes, & Franjoine 2009 Be transient and disappear Preterm infants Medically fragile children Continue as Hypotonic CP Later be diagnosed as Athetoid, Ataxic, or Spastic CP May:

McElroy, Haynes, & Franjoine 2009 Be part of an obvious or later diagnosed genetic syndrome Down Syndrome Prader-Willi Joubert Syndrome Other syndromes Fetal alcohol syndrome (FAS) Fragile X syndrome Maternal drug abuse May:

McElroy, Haynes, & Franjoine 2009 A muscle fiber type disorder Sensory integration disorder MR Autism May be:

McElroy, Haynes, & Franjoine 2009 Cognition Neuromuscular System Sensory System Musculoskeletal System Regulatory Gastrointestinal Cardiopulmonary Integumentary

McElroy, Haynes, & Franjoine 2009 Variable: Child to child Etiology Cognition often underestimated Flat affect Appears “slow” or “lazy” Latency of response time

McElroy, Haynes, & Franjoine 2009 Abnormally low muscle resting tone Abnormally low resistance to being lengthened Feels “soft” when handled Described as “floppy”

McElroy, Haynes, & Franjoine 2009 Impaired Muscle Synergies Impaired Muscle Activation Inability to Initiate, Sustain, Terminate Inability to Initiate, Sustain, Terminate Insufficient Co-activation

McElroy, Haynes, & Franjoine 2009 Holding joint positions in midrange is difficult Move quickly through transitions Tend to work at end ranges Decrease degrees of freedom distally Hyperextention of elbows and knees

McElroy, Haynes, & Franjoine 2009 Difficulty initiating muscle contraction Threshold for fiber firing Insufficient number of fibers recruited Slow to respond Response is then short-lived “Good baby”…later “lazy” May have a flat affect In supine “look flat”

McElroy, Haynes, & Franjoine 2009 Difficulty in sustained holding against gravity…especially postural muscles Look like gravity is pulling them down Have a “belly” when upright Often turns muscles off to quickly i.e. Collapse when standing

McElroy, Haynes, & Franjoine 2009 Impaired Motor Execution Impaired Modulation and Scaling of Forces Impaired Timing and Sequencing Impaired Timing and Sequencing Excessive overflow of Intra- Interlimb contractions Excessive overflow of Intra- Interlimb contractions

McElroy, Haynes, & Franjoine 2009 Phasic bursts of movement Little grading – moves quickly to end ranges Overshoots target or strikes target inappropriately

McElroy, Haynes, & Franjoine 2009 Primary— Difficulty grading agonists and antagonists Timing and sequencing difficulties may be secondary to initiate, sustain, and strength issues

McElroy, Haynes, & Franjoine 2009 Impaired Force Generation Strength: the ability to contract a muscle to a sufficient degree to impact the task Primary inability to reach threshold for muscle firing inability to recruit enough muscle fibers Secondary Little muscle holding: decreased strength/atrophy Changes in muscle fiber type 2°to phasic use

McElroy, Haynes, & Franjoine 2009 Anticipatory Postural Control— Probably not a primary impairment Difficult with latency of initiation Often they may anticipate a movement and “lock out their joints” in anticipation Anticipation may be present…just not appropriate

McElroy, Haynes, & Franjoine 2009 Poverty of Movement “Poverty”--they don’t move much Happy to stay in one place Movement repertoires are somewhat limited Secondary to strength, alignment, and stability available to them during development Movements in the frontal and, especially, the transverse planes are less frequently seen

McElroy, Haynes, & Franjoine 2009 Fractionated or Dissociated Movements Often use pure reciprocal innervation rather than co-contraction Movements may be “too dissociated” Need to control degrees of freedom to support purposeful isolated control Often fix distally Splaying of fingers Plantar-flexion of ankles

McElroy, Haynes, & Franjoine 2009 Vision Vestibular Somatosensory

McElroy, Haynes, & Franjoine 2009 Primary Impairments Refractory errors Visual field loss Strabismus Cortical visual impairment not as common as in SQ Secondary Impairment Uses eyes for postural stabilization

McElroy, Haynes, & Franjoine 2009

Difficulty using: proprioceptive information tactile information Primary impairment If inappropriate firing of receptors Secondary impairment If caused by lack of experience due to little movement, ability to read the input didn’t develop well

McElroy, Haynes, & Franjoine 2009 “ the ability of the nervous system to perceive, interpret, modulate, and organize sensory input for use in generating or adapting motor responses… (Miller & Lane 2000) Degree of difficulty varies widely by etiology of the hypotonia

McElroy, Haynes, & Franjoine 2009 Bones: Changes are usually secondary to static positons Plagiocephaly Flattend ribcage Kyphosis Shoulder instability Hip instability

McElroy, Haynes, & Franjoine 2009 Muscles: Atrophy Weakness Fiber type changes Muscle shortening Muscle overlengthening Connective tissue:

McElroy, Haynes, & Franjoine 2009 Muscles: Atrophy Weakness Fiber type changes Muscle shortening Muscle overlengthening Primary or Secondary Impairments?

McElroy, Haynes, & Franjoine 2009 Connective Tissue: Hyperextensible joints Ligamentous laxity Primary or Secondary Impairments?

McElroy, Haynes, & Franjoine 2009 M R Franjoine & M P Haynes 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 functions Functional activitiesFunctional activity limitations D. Social functionsParticipationParticipation restriction + Domains - Dimensions From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

McElroy, Haynes, & Franjoine 2009 Antigravity postures are difficult so use phasic bursts of movement Move quickly to ends of range Rest on ligaments, joint capsules, and bones

McElroy, Haynes, & Franjoine 2009 Use wide BOS in both UEs and LEs Move quickly to ends of range Rest on ligaments, joint capsules, and bones

McElroy, Haynes, & Franjoine 2009 Postures: Hyperextends neck and “rests” head back Mouth is often open Shoulder complex is often elevated to support head Lower extremities are widely abducted and externally rotated Movement: Even neck extension is phasic…head may fall forward without control No lateral weight shifts!!!!

McElroy, Haynes, & Franjoine 2009

Postures: Prefers arms abducted and legs abducted Body “melted” onto the floor Movement: Antigravity of extremities difficult Sometimes “walks” extremities with hand movements Can’t lift head against gravity “Flings” extremities

McElroy, Haynes, & Franjoine 2009

Postures: Retains flexed spinal position with hyperextended head resting position Sometimes looks like their chest “folds” in front Uses UEs for support (hyperextended elbows) May use feet as hands Posteriorly tilted pelvis BOS is very wide, knees flexed or extended

McElroy, Haynes, & Franjoine 2009 Movement: Keeps the COM in the middle of the BOS Will pivot rather than rotate spine Often transitions out of sitting in the sagittal plane with legs abducted

McElroy, Haynes, & Franjoine 2009

Postures: Hyperextension at the neck and elbows UEs abducted Hips and knees flexed greater than 90° Hips abducted Movement: Moves extremities rapidly with longer periods of 4s support with extremities “locked” when possible Much rather scoot on bottom!!!

McElroy, Haynes, & Franjoine 2009

Postures: Support with UEs Hips are abducted Hips rest on feet or floor Movement: Difficult position to maintain Will not transition to ½ kneel, pushes with legs at the same time to get to standing

McElroy, Haynes, & Franjoine 2009

Postures: Still like hyperextended neck and kyphotic upper spine UEs used to increase stiffness of trunk Pelvis may be anteriorly or posteriorly tilted Wide BOS in LEs Knees hyperextended, out-toeing

McElroy, Haynes, & Franjoine 2009 Movement: Legs may “fold” unexpectedly Difficulty shifting weight laterally to unweight one leg for gait Wide BOS and short steps make gait awkward and inefficient

McElroy, Haynes, & Franjoine 2009

M R Franjoine & M P Haynes 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 functions Functional activitiesFunctional activity limitations D. Social functionsParticipationParticipation restriction + Domains - Dimensions From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

McElroy, Haynes, & Franjoine 2009 LOCOMOTOR SKILLS Independent, efficient upright mobility difficult Coordination and safety is a concern COMMUNICATION Though may be difficult to understand, communication is usually verbal BASIC ADL’S Usually can master ADLs May be more limited by cognition than motor ability

McElroy, Haynes, & Franjoine 2009 M R Franjoine & M P Haynes 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 functions Functional activitiesFunctional activity limitations D. Social functionsParticipationParticipation restriction + Domains - Dimensions From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

McElroy, Haynes, & Franjoine 2009 Accepted by family…”good child” or “lazy child” Often not accepted by peers due to latency of responses and communications Sometimes problems safely accessing playgrounds and community centers

McElroy, Haynes, & Franjoine 2009 Work upright whenever possible Attend closely to alignment Narrow the base of support Emphasize weight shifts May need to increase attention and/or arousal

McElroy, Haynes, & Franjoine 2009 Increase proprioception by activating co- contraction around joints…holding and graded movements Build strength working in midranges… concentric and eccentric

McElroy, Haynes, & Franjoine 2009 “Good” babies and children are often ignored The static situation of these children interferes with exploration and learning Don’t under-estimate the power of the biomechanical limits these children face.