Normal Development of Movement

M Tshabalala

Normal Motor Development

Principles of Development:
Development is a continuous process from conception to birth Sequences of development is the same in all children but the rate of development varies Development is related to the maturation of the CNS Mass movts are replaced by specific individualized responses. Dev is in a cephalocaudal direction. Certain primitive reflexes must be lost before the corresponding voluntary movements develop.

Development of Locomotion
Developmental sequence is from the development of head control, to mature walking, running and skipping Various postions used to assessing developmental sequences are: Ventral suspension Prone Supine (PTS) Sitting & upright posture/ standing

Development of Locomotion (cont)

PATTERNS OF MOTOR ABILITIES

Immature: functioning like a younger child or baby, may be due to MR or physical damage
Pathological: due to particular paralyses, myopathies or neuropathies Compensatory Patterns: occur in all motor-delayed & motor-disordered children. NB: There are many postures and patterns of locomotion in rolling, creeping, crawling and walking. Normal or stromger muscles may be overused, balance reactions exaggerated, child have difficulty adjusting to gravity or mechanical forces

Development of Locomotion (cont)

Posture of the Newborn:
Predominantly in flexion Knees and elbows remain flexed

Hips tend to abduction,

Shoulders mildly retracted

NB: Flexion is accentuated in prone by the presence of Tonic Labyrinthine Reflex (TLR)

Development of Locomotion (cont)

Scholars who have contributed to the vast knowledge of neurological & developmental examination of the newborn are: - Albrecht Peiper, Andre Thomas, Madame Saint-Anne Dargassies and Heinz Prechtl

Development of Locomotion (cont)

CNS Evaluation of the Newborn:
Sensory-motor behaviour starts developing in utero and are

the result of reflex activity

Predominates babys mvts for 3 to 6 months post delivery

Integrated into secondary reflexes and complex reactions seen throughout life

Knowledge of normal reflexes and reactions is vital for therapists working with children, these enables them to detect any delay or abnormality in the childs development.

Development of Locomotion (cont)

REFLEXES & REACTIONS:

They are divided into 5 groups

1) Primitive reflexes 2) Spinal reflexes 3) Brainstem reflexes 4) Midbrain reactions

5) Cortical reactions

Reflexes and Reactions

PRIMITIVE REFLEXES:

Appear in fetal development to 6 months

Then become assimilated into more complex movts Only reappear in response to extreme stress, effort or CNS damage

Provide an early foundation of posture and movements

Seem to have survival role

Reflexes and Reactions

PRIMITIVE REFLEXES are the following:

Moro reflex: position baby head and trunk at an angle of about 45 0 from
the couch OR supported on palm of the hand. Sudden release of the hand from the head startles the baby who responds by abduction and extension of the arms through extension.

Rooting reflex: a touch to the corner of the mouth stimulates the infant to seek the nipple
Sucking/ Swallow reflex: stimulus to the hard palate elicits a response of the tongue moving forwards and triggering off a rhythmic sucking action

Gag reflex: present throughout life, elicited by touch to the soft palate and prevents fluid and food from being aspirated.
Grasp reflex: elicited by placing a finger into the childs ulnar side. The childs fingers will flex and grip the examiners finger. Disappear in 2-3 mo

Primitive Reflexes (continued..)

Placing reaction: elicited by bringing the anterior aspect of the tibia or ulnar against the edge of a table. Response is the child lifting up the leg to step onto OR elevates the hand onto the table. Stepping/ Walking reflex: holding the baby upright on the table so that the sole of the foot presses on it, will initiate reciprocal flexion and extension of the legs simulating walking. Disappear by 5-6 weeks Startle reflex: a sudden noise or tapping the sternum, elicit a similar response to the Moro but elbows remain flexed and hands closed. Plantar grasp reflex: elicited by gently stimulating the sole of the food behind the toes. Toes will flex

Spinal Level Reflexes

SPINAL REFLEXES:

Are phasic or movt reflexes which co-ordinate muscles of extremities in patterns of either total flexion or total extension.
May be present in normal child from birth to 2 mo

Positive reactions beyond 2 mo indicate delayed maturation of the CNS

Negative rxn are normal

Complete domination by these spinal reflexes result in apedal creature

Spinal Level Reflexes

SPINAL REFLEXES ARE THE FOLLOWING: Flexor withdrawal rxn: supine, legs extended, stimulate sole

of the foot

Positive rxn: child flex whole leg Negative rxn: leg remain in extension

Extensor Thrust rxn: supine, one leg flexed, the other extended, stimulation of the flexed foot Positive rxn: extension of the leg Negative rxn: controlled maintaining of the leg in flexion

Crossed extension rxn: supine, one leg flexed the other extended. Stimulated by flexing the extended leg. Positive rxn: on flexion of the ext. leg, the opposite or initially flexed leg will extend

Brianstem Level Reflexes

THEY ARE: Static postural reflexes that effect changes in the distribution of muscle tone throughout the body

Respond to a change in position of the head and body in space (labyringths stimulation)
Also respond to the change in postion of the head in relation to the body (stimulation of proprioceptors of the neck) Positive OR negative rxns to brainstem reflex testing may be present from birth to 4 6 mo of life

Positive rxns beyond 6 mo indicate delayed CNS maturation

Negative rxn after 6 mo are normal. Complete domination of these relfexes result in an apedal creature

Brianstem Level Reflexes

BRAINSTEM LEVEL REFLEXES ARE: Tonic Labyrinthine Reflex (TLR):
1) Child positioned in supine, extremities extended, stimulated by moving the child to an upright position/ lowering back OR passively flexing the neck Positive rxn: extensor tone dominates, arms drawn up in flexion above level of the head Negative rxn: no increase in extensor tone 2) Child in prone:

Positive rxn: unable to lift head up, retract shoulders, and extend the trunk, falls on his face when place into the kneeling position
NB: Normal up to 4 months

Brianstem Level Reflexes

BRAINSTEM LEVEL REFLEXES ARE: Symmetrical Tonic Neck Reflex (STNR):
1) Child positioned in quadruped OR over the examiners knees, stimulate by flexing the head passively: Positive rxn: arms go into flexion ( UL flexor tone dominates) and the legs extend (LL extensor tone dominates) Negative rxn: no change in tone in the arms and legs 2) Child in same position, passively extend his head: Positive rxn: arms extend (increase in extensor tone), legs flex (increase in flexor tone) Negative rxn: No change in tone NB: Positive rxn normal upto 4 6 mo of age

Brianstem Level Reflexes

Asymmetrical Tonic Neck Reflex (ATNR):
Child in supine, head in neutral position, arms and legs extended. Passively turn the head to one side: Positive rxn: extension of the arm and leg on the face side (Increse in extonsor tone) and flexion of the the arm and leg on the occipital side (increase in flexor tone

Negative rxn: no change in tone in the arms and legs

NB: Normal from 4 6 mo

Positive Supporting Rxn:

Hold the child in standing, bounce him several times on the sole of his feet
Positive rxn: Increase in extensor tone in the legs with plantarflexion of the feet. Normal from 3 8 months ASSOCIATED REACTIONS

Mid-brain Level Reflexes

Def: Also known as righting reactions (RR), interact with each other establish normal head and body relationship in space as well as in relation to each other. They are responsible for development of postural control and the ability to change position in space. Labyrinthine Righting Reactions (LRR):

Appear from 1 2 mo of age and present throughout life. Enable the baby to clear airways when in prone lying
Neck Righting Reaction (NRR):

This makes facilitation using the head as a Keypoint of movement possible i.e. the body follows the position of the neck. From birth to 6 mo Body RR acting on Body: these provide segmental rotation, from 6 to 18 months

Mid-brain Level Reflexes

Body RR acting on Head: Enable the child to hold his head in space. When the child is in prone, pressure on the abdomen and support on arms will aid head extension. Optic Righting Reaction:

This is integrated at mid-brain as well as at the cortical level. Starts appearing from 6 months throughout Amphibian reaction:

When child is in prone lying, lifting his pelvis will cause flexion of the arm and leg on the same sade. Appears from 6 mo and is maintained throughout life

Cortical Level Reactions

These reactions are mediated by the efficient interaction of the cortex, basal ganglia and the cerebellum

Maturation of the equilibrium rxn brings the individual to the human bipedal stage of motor development.
Emerge from 6 mo, consist of postural adjustments of the whole body Serve to maintain balance over the existing base when the equilibrium of the body is disturbed. Necessitate rotation, thus are dependent on postural control between flexion & extension They are essentially ERs, develop a stage behind the level reached by the child. Tested in supine, prone, 4pt kn & standing