functional physiotherapy

Cranial deformities - The clumsy child - Posture - Recommended reading - GM - Pain in infants - theory motor development - brain plastcity

 

Cranial deformities in the Market Place June 2007
The osteopathic and paediatric physiotherapists approach.
By Esther de Ru
Cranial deformity is a fairly common feature of new born babies. The pressure and strains during normal child birth on mother and baby are enormous.
One of the biggest problems with human reproduction is that being two legged animals with large heads, the limited size of the pelvis makes birth a tight squeeze. Ingeniously, the body gets around this by producing hormones that loosen up the pelvic ligaments in the mother and not fusing the cranial bones of the baby until after birth. This means that during birth, the skull is squeezed through the birth canal changing shape as it does so. During a complex birth, such as unusually long labour, ventouse delivery, premature birth, intrauterine constraint, the deformity can be more severe and long lasting.
Often children are born with “funny shaped heads” and parents are often worried that these deformities will be permanent. Over the following weeks most children will improve. The action of suckling is thought to act as a cranial pump that encourages expansion of the skull. Sometimes a baby with a cranial distortion will be unable to feed well as a result of their deformity. This problem can usually be corrected. Both paediatric physiotherapists and osteopaths have been trained to assess and treat these children. Both professionals will refer your baby back to the paediatrician in the presence of other underlying conditions. Physiotherapy is different to osteopathy but both therapies complement each other very well.
Physiotherapy treatment
The physiotherapist will educate parents to prevent further positional deformity and will evaluate spinal movements and the total sensory-motor development. Therapy consists of various tactile stimuli, stretch, pressure thereby stimulating weakened or tightened muscles in neck or trunk. Parents are instructed to facilitate correct movement by means of posture during feeding, positioning in bed or pram and by playing games with their baby. Back to Sleep & Tummy to Play – CPS fact sheet tummy time for tots www.csp.org.uk
Osteopathic Treatment
Treating a baby is different from treating an adult in that we never use manipulations. Instead babies can be treated by gentle and safely using cranio-sacral therapy. This type of treatment can release tension in the membranes in the skull that may have occurred during birth and this release of cranial tension encourages expansion of the skull to correct the deformity. We also use gentle stretching techniques on the neck to remove muscular tension. With this type of treatment the earlier you start the better. As time goes by, the cranial bones become less flexible and the deformity may become more permanent. My youngest patient was treated in the first 12 hours!

The clumsy child  (DCD- Developmental Co-ordination Disorder). Article Market Place
Many terms are used to describe co-ordination difficulties: DCD, dyspraxia, perceptual-motor dysfunction and clumsy child syndrome. Specialists have agreed to use DCD as the overall term describing these children.
Children with these problems have difficulty processing information (vision, hearing, speech, balance) and they find it difficult to learn motor skills. Their movements are often hesitant and slow or clownesk, they often have problems sitting still, carrying out instructions and organising themselves. They can be disruptive in class, have difficulty coping with text from a book, eating with knife and fork, dressing or undressing and writing.
We all know them, the clumsy ones, always falling over a straw, bumping into people, spilling everything , balance problems, dislike (difficulty) with ball activities, games, playing outside) and having problems with their coordination. A lot of these kids are misunderstood.
These children fall into 2 categories.
1. the clumsiness is a sign or symptom of a medical or psychological condition   
2. no hard neurological signs or biochemical, anatomical or sensory defects are found but nevertheless they have extraordinary problems acquiring motor skill needed to cope with everyday life. Studies have shown these children do not simple “grow out of” their difficulties. Without intervention the problems persist and are frequently accompanied by an increasing number of other problems at home and school.
Although not always curable, children can improve dramatically with appropriate treatment. Paediatric physiotherapists can asses your child (strength, motor skills, activity level, sensitivity to sensory stimulation) before planning a treatment programme.
Esther de Ru  paediatric physiotherapist

Marketplace January 2008
POSTURE- POSTURE- POSTURE-POSTURE article Market Place
Everybody knows they should be looking after their back and lifting objects correctly BUT very few people actually do so.
Our body is actually made to move and do lots of physical labour.
The last decades physical labour is diminishing and we have all become sitting beings.

1. we encourage babies to sit up straight as soon as possible-
2. we bring our kids to school in cars or on bikes-
3. we sit in cars, behind a desk, behind our computer or in front of the television ( so do our kids) -
4. when we are old we sit more because we have worked hard our whole life –

Proper posture keeps bones and joint in correct alignment so that muscles are being used properly and economically.
Bad posture-  increases abnormal wear of joint surfaces and fatigues muscles  not being used efficiently. It can cause backache and neck pain, children included. It can cause the spine to stiffen in abnormal positions in the long run.
It does not flatter your appearance at all.
¿How many slough potatoes do you know?
I have seen many beautiful people in tailor made suites but with a horrible posture looking terrible!

What I recommend all patients is:
Look after your posture and give someone close permission to nag and “help”.
Move- after about 20 minutes in one position the blood flow will decrease so we should move.
Think before you lift or take in a position you have to stay in for a while.
Exercise, stretch, try to learn to listen to the signals your body is sending you. (everybody knows the sensation of wanting to stretch when in a long meeting)… do so.
Have fun…

Scoliosis article Market Place                                               

With scoliosis the spinal curves are side to side instead of straight. It is confirmed by X-ray ( Cobb angle ). The female to male ratio is 6:1. There are many causes of scoliosis. Sometimes vertebrae are incompletely formed or misshapen. Sometimes people who have legs of different lengths develop a scoliosis and in other cases, diseases cause scoliosis.
The most common type is called idiopathic scoliosis. In idiopathic scoliosis some of the vertebrae are rotated because the muscles attaching the vertebrae to the ribs may not be pulling with equal force. One set of rib muscles pulls harder causing the vertebrae to twist and move out of a straight line down the back. This may also cause the ribs on one side of the back to stick out more, causing a hump.
The idiopathic infantile scoliosis has an early onset ( 0-3 years) and 80-90% resolves. Therapy is not always necessary but if the scoliosis is progressive surgery is often needed.
The juvenile scoliosis is seen between 4-9 years, therapy is observational and a  brace is needed if the scoliosis is progressive.

The adolescent scoliosis  is seen from 10 years onward. If the Cobb angle is >30° and progressive, a brace is needed. Surgery is only considered after bracing has failed, the curvature is severe ( > 50° ) and progression is expected beyond an acceptable degree of deformity.

Bracing: a brace can be effective  and can at best slow or stop the scoliosis progress. It does not correct the deformity.  Braces have various models and are custom made. The SpineCor Brace is relatively new and results are promising.

Physiotherapy is not always necessary.  When prescribed, exercise programs are usually initiated in addition to, and not instead of bracing treatment. Careful monitoring of curve angles remains essential, regardless of exercise. Scoliosis is not caused by a deficiency of strength or flexibility, and therefore exercise is relatively ineffective in correcting scoliosis.
Scoliosis is not a result of exercise, and therefore normal physical activities can be enjoyed by people with scoliosis without a problem.

How can you prevent scoliosis developing in young people getting worse? Avoid carrying heavy bags on one shoulder. Get a rucksack type bag and wear it properly or regularly alternate carrying arms and shoulders.  If you are a one sided sports person e.g. Javelin thrower, hurdler or tennis player, at the end of each practice make sure you throw a few times with your wrong arm or hit a few balls with the other arm.  The above  information is from the following website. http://www.sportsinjuryclinic.net/

For more information go to:
http://www.scoliosis.org/index.php  home of the National Scoliosis Foundation
http://www.youngwomenshealth.org/scoliosis-article.html a patient guide and
www.spinecor.com

The assessment of the quality of General Movements

Recommended Reading

1. Bos AF, Van Loon AJ, Hadders-Algra M, Martijn A, Okken A, Prechtl HFR.

Spontaneous motility in preterm, small for gestational infants. II Qualitative aspects.  Early Hum Dev 1997; 50:131-47.

2. Bos AF, Martijn A, Van Asperen RM, Hadders-Algra M, Okken A, Prechtl HFR. Qualitative assessment of general movements in high risk preterm infants with chronic lung disease requiring dexamethoasone therapy. J.paedatr 1998; 132:300-6.
3. Bos AF, Martijn A, Okken A, Prechtl HFR. Quality of general movements in  preterm infants with transient periventricular echodensities. Acta Paediatr 1998;87:328-35.
4. Bouwstra H, Dijck-Brouwer DAJ,Wildeman JAL, Tjoonk HM, Van der Heide JC, Boersma ER, Muskiet FAJ, Hadders-Algra. Long-chain polysaturated fatty acids have a positive effect on the quality of general movements of healthy term infants. Am J. Clin Nutr 2003;78:313-8.
5. Bouwstra H, Groen SE, Hadders-Algra M. Quality of general movements and cognitive and behavioural outcome at 9 to 12 years in children without cerebral palsy. Submitted for publication.
6. Cioni G, Ferrari F, Einspieler C, Paolicelli P, Barbani MT Precht HFR. Comparison between observation of spontaneous movements and neurological examination in preterm infants. J. paediatr 1997;130:704-11
7. Cioni G, Prechtl HFR, Ferrari F, Paola B, Einspieler C, Roversi MF. Which better predicts later outcome in full term infants: quality of general movements or neurological examination? Early Hum Dev 1997;50:71-85.
8. De Graaf-Peters VB, De Groot-Hornstra AH, Dirks T, Hadders-Algra M. Specific postural support promotes variation in motor behaviour of infants with minor neurological dysfunction. Dev Med Child Neurol 2006, 48: 966-972
9. Einspieler C, Prechtl HFR, Bos AF, Ferrari G, Cioni G. Prechtl´s method on the qualitative assessment of general movements in preterm, term and young infants. Clin Dev Med No 167. London: Mac Keith Press, 2004.
10. Ferrari F, Cioni G, prechtl HFR. Qualitative changes of general movements in preterm infants with brain lesions. Early Hum Dev 1990;23:193-231.
11. Ferrari F, Cioni G, Einspieler C, Roversi MF, Bos AF, Paolicelli PB, Ranzi A, Prechtl HFR. Cramped synchronized general movements in preterm infants as an early marker of cerebral palsy. Arch Pediatr Adolesc Med 2002;156:460-7.
12. Groen SE, de Blécourt ACE, Postema K, Hadders-Algra M. Quality of general movements predicts neuromotor development at the age of 9-12 years. Dev Med Child Neurol 2005;47:731-8.
13. Hadder-Algra M. General movements in early infancy: what do they tell us about the nervous system? Early hum Dev 1993;34:29-37.
14. Hadders-Algra M. The neuronal Group Selection Theory; an attractive framework to explain variation in normal motor development. Dev Med Child Neurol 2000a;42:566-72.
15. Hadders-Algra M. The Neuronal Group Selection Theory: promising principles for understanding and treating developmental motor disorders. Dev Med Child Neurol 2000b;42:707-15.
16. Hadders-Algra M. Two distinct forms of minor neurological dysfunction; perspectives emerging from a review of data of the Groningen Perinatal Project. Dev Med Child Neurol 2002;44:561-71.
17. Hadder-Algra M. Developmental Coordination disorder: Is clumsy motor behaviour caused by a lesion of the brain at early age? Neural Plast 2003;10:39-50.
18. Hadders-Algra M. General movements: a window for early identification of children at high risk of developmental disorders. J. Pediatr 2004;145:S12-18.
19.  Hadders-Algra M, Groothuis AMC. Quality of general movements in infancy is related to the development of neurological dysfunction, attention deficit hyperactivity disorder and aggressive behaviour. Dev Med Child Neurol 1999;41:391-91.
20. Hadders-Algra M, Prechtl HFR. Developmental course of general movements in early infancy. I: Descriptive analysis of change in form. Early Hum Dev 1992;28:201-14.
21. Hadders-Algra  M, Klip-Van den Nieuwendijk AWJ, Martijn A, Van Eykern LA. Assessment of general movements: towards a better understanding of a sensitive method to evaluate brain function in young infants. Dev Med Child Neurol 1997;39:88-98.
22. Hadders-Algra M, Mavinkurve-Groothuis AMC, Groen SE, Stremmelaar EF, Martijn A, Butcher PR. Quality of general movements and the development of minor neurological dysfunction at toddler and school age. Clin Rehabil 2004;18:287-99.
23. Hadder-Algra M, Nakae Y, Van Eykern LA, Klip-Van den Nieuwendijk AWJ, Prechtl HFR. The effect of behavioural state on general movements in healthy fullterm newborns. A. Polymyographic study. Early Hum Dev 1993;35:63-79
24. Hadder-Algra M, Van Eykern LA, Klip-Van den Nieuwendijk AWJ, Prechtl HFR. Developmental course of general movements in  early infancy. II. EMG correlates. Early Hum Dev 1992;28:231-52.
25. Hopkins B, Prechtl HFR. A qualitative approach to the development of movements during early infancy. In: Continuity of neural functions form prenatal to postnatal life. Prechtl HFR ed. Clin.Dev.Med. No 94. Oxford: Blackwell Scientific Publications; 1984:179-97.
26. Mazzone L, Mugno D, Mazzone D. The general Movements in children with Down syndrome. Early Hum Dev 2004;79:119-30.
27. Prechtl HFR. The behavioural state of the infant- a review. Brain Res 1974;76:185-212.
28.  Prechtl HFR. Qualitative changes of Spontaneous movements in fetus and preterm infant are a marker of neurological dysfunction. Early Hum Dev 1990;23:151-8.
29.  Prechtl HFR. General movement assessment as a method of developmental neurology: new paradigms and their consequences. Dev med Child Neurol 2001;43:863-42.
30. Prechtl HFR, Nolte R. Motor behaviour of preterm infants. In: Continuity of neural functions from prenatal to postnatal life. Prechtl HFR ed. Clin Dev med No 94. Oxford: Blackwell Scientific Publications; 1984:79-92.
31. Prechtl HFR, Eindspieler C, Cioni G, Bos A, Ferrari F, Sontheimer D. An early marker of developing neurological handicap after perinatal brain lesions. Lancet 1997;339:1361-3.
32. Prechtl HFR, Ferrrari F, Cioni G. Preditive value of general movements in asphyxiated fullterm infants. Early hum Dev 1993;35:91-120.
33. Touwen BCL. How normal is variable, or how variable is normal? Early Hum Dev 1993;34:1-12

NB More about the international course – Assessing  the GM´s-  can be found on:
www.developmentalneurology.com  
email address: prof. dr. mrs M. Hadders-Algra  is  m.hadders-algra@med.rug.nl

Esther de Ru BPT,MOT,PPT Spain tel 0034686782852 email estherderu@gmail.com

                                8° Congresso Nacional de Pediatria
                             Vilamoura Portugal    1-5 outubro 2007
Oral presentation  05-10-07
 
Ladies and Gentlemen,

Thank you all and thanks to prof. M. Hadders- Algra for making it possible for me  to introduce the GM´s to you all.
As a paediatric physiotherapist I am the “outsider” in your midst.
Because of the health situation in Holland both doctors  and
paediatric physiotherapists are be trained to assess the GM´s  and they can do
so in the clinic and in the home situation. Many premature children are
treated at home after their release from Hospital.

Because of the limited time I will say little so that we can actually watch the GM´s .

1.The basic principles. The GM´s were first introduced by Prechtl in 1984.
Present from 7-8 wk PMA ( he distinguished 3 developmental stages ) to 4 months post term. They are gradually replaced by goal directed movements

The foetal or  preterm GM´s 28 wk- 36/38 wk PMA postmenstrual age
Extremely variable movements, including many pelvic tilts and trunk movement

The writhing GMs  36/38 – 46/52 wk
Something forceful has been added to the variable movement (writhing). In comparison to the preterm GM´s,  these seem to be somewhat slower and there is less participation of trunk and pelvis.

The fidgety GM´s  46/52- 54-58 PMA (4mth)  – they gradually become more goal directed. A continuous flow of small and elegant movements occurring irregularly all over the body, i.e. head, truck and limbs participate. The small movements are sometimes superimposed by large and fast movements

By watching the GMs,  we assess:
Variation, complexity and fluency and fluency is the first property to disappear when a minor degree of dysfunction is present in the nervous system. Subtle dysfunctions of NS result in movements with a jerky of stiff appearance or in tremulous movements.
the normal optimal,- abundantly variable and complex and also fluent. They are relatively rare, 10-20% of 3mnth old infants show GMs of such a beautiful quality
the normal suboptimal-  sufficiently variable and complex but usually not fluent. The majority of infants show normal suboptimal movements.
the mildly abnormal- are insufficiently variable and complex and not fluent. About  20-25% of 3 month old infants in the general population show mildly abnormal GM´s
the definitely abnormal -they have little or no complexity, variation and fluency. Some children show nothing but so called cramped-synchronized patterns  (suddenly occurring en-bloc movements) in which trunk and flexed or extended limbs stiffly move in synchrony. They are considered pathological when frequently seen.

2. the classification of GM quality.
In her editorial ( about foetal movements and the young nervous system in the nr 48 of Developmental Medicine & Child neurology 2006.) Hilary Hart noted that  the GM assessment has received cautious recognition by some largely because of its apparent subjective nature.
The Gestalt (elegance and comfort) evaluation  of complexity and variation are essential  and can be learnt in 2 days ( not 5 as she stated).
Use of the video is a key feature in the training  and assessment and learning to recognise the important signs takes time and practice to become a second nature.
Because I have worked in the 1st echelon I feel most comfortable judging fidgety GM´s myself. Therapists and doctors working in the ICU will see the foetal and writhing GM´s a lot more.

3. methodological issues
Yes it is time consuming- because in real life too many errors can be made, assessing later is a much better option.
The child has to be in a good state ( 4 )- In supine position, and until term age, with diaper only.
From term age on- supine in underwear.
The basis principles van be learned in 2 days.

4. Significance of abnormal GMs

1. sensitive tool
2. the GM´s are relatively stable within the GM phase and can be unstable in between phases
3. predictive quality is highest with a series of assessments from preterm to fidgety.
4. Best predication – of a single assessment is fidgety age
5. constant persistence of abnormal GMs imply a very high risk for developing CP or complex form of minor neurological dysfunction specific  OR
6. various articles have associated abnormal GM´s with coordination problems

and fine motor problems at 9-12 yrs, vulnerability to develop attention problems, hyperactivity and withdrawn behaviour 9-12 yrs

5. Recommended reading.
I have a handout of all the recommended reading, website and email address of prof. Hadders.
The best is to follow a course. Mrs Hadders-Algra  is willing to present a course in Portugal if there are enough participants. ( 20-30)
As a physiotherapist I suggest a neonatologist and a paediatric physiotherapist working in a team follow the course together.

conclusion
The GM assessment is non invasive and therefore suitable to be used in the intensive care setting, neonatal nurseries and the follow-up setting. There are limitations and
it cannot replace the MRI  but it can play an important part role in the integrated neurodevelopment assessment of the foetus and young infant.

Brain plasticity: