Growth and development - kau



Growth and development

➢ Pregnancy is actually 280 days, or 40 weeks measured from the first day of the last menstrual period,, divided into three trimesters.

➢ The fetus develops over many months’ time, but the first few months are the most critical.

❑ All baby’s major organs begin forming in the early weeks of pregnancy, some even before realizing pregnancy.

❑ Therefore, mother's health, nutrition, and avoidance of harmful substances are important even before pregnancy begins.

❑ Anything mothers eat, drink, breathe, or touch can affect baby’s development, especially in the very sensitive period beginning at conception.

Introduction to Normal Growth and Development

They are two terms refer to continuous dynamic processes occurring from conception to maturity and follow certain dynamic sequences.

-They are parallel to each other in normal child

-They are consistent, predictable and sequential

Growth

It is an increase of physical size of the whole body or organ of different parts of the body.

It is an increase of the number and the size of each individual cell

The measuring scales are related to:

• weight which is measured by Kg., gm or pound, Ounce.

• Height Which is measured by Cm, Feet.

Normal growth of young children

Regular measurements of child's height, weight and head circumference and plotting them on a growth chart are a good way to see if the child is growing normally.

Although many parents are preoccupied by where their child is on the growth charts and often worry if their child is small or near the bottom of the growth chart, it is child's rate of growth that is the most important factor to consider when evaluating if child is growing and developing normally.

If child is following his growth curve, then he is likely growing normally

Growth chart

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• Keep in mind that some children can normally move up or down on their growth curves when they are 6-18 months old.

• As long as they are not actually losing weight, and they have no other symptoms, such as persistent diarrhea, vomiting, poor appetite or having frequent infections, then it may be normal to move down on your growth percentiles.

• Older children should stick to their growth curves fairly closely though.

General guidelines for younger child growth rates:

• The majority of babies born full-term ,

i.e. 40 weeks (280 days), weight from just over 2.6 to 3.8 kilos , and they

are between 48 - 53cm long, head circumference is between 34 – 40 cm.

• Infants born before the completion of 37 weeks of gestation are called premature.

Weight:

• 2 weeks - regains birth weight and then gains about 1 1/2 - 2 pounds a month

• 3 months - gains about 1 pound a month

• 5 months - doubles birth weight

• 1 year - triples birth weight and then gains about 1/2 pound a month

• 2 years - quadruples birth weight and then gains about 4-5 pounds a year

• 9-10 years - increased weight gain as puberty approaches, often about 10 pounds a year

Height:

• 0-12 months - grows about 10 inches (25 cm).

• 1-2 years - grows about 5 inches (13 cm).

• 2-3 years - grows about 2 1/2 inches( 8 cm) a year.

• Most children will double their birth height by 3-4 years of age.

• 3 years to puberty - grows about 2 inches (5cm) a year

Head Circumference:

• 0→3 Months - ↑ 2 centimeters a month

• 4→6 Months - ↑ 1 centimeters a month

• 6→12 Months -↑ 1/2 centimeter a month

• 1→ 2 Years - ↑ 2 centimeters a year

Remember

that these are general guidelines though that the child may grow a little

more or a little less than this each year.

Factors Affecting Growth:

• Mother‘s health during pregnancy.

• Period of pregnancy.

• Multiplication of labor.

• Gender.

• Nutritional factors. Health status of the baby.

Development

- It is a progressive increase in skill and capacity of function.

i.e increase of functional activity, indicates development

of millstones. (The ability to achieve specific function at certain age)

It is measured by specific scales that determines the different

age to achieve certain function.

e.g.:

The Denver Development Screening Test, Test form with 105 items.

Bruininks – Oseretesky. Form for eight subtests.Test of Motor Proficiency.

The Denver Development Screening Test (DDST)

It includes 4 areas of development :

1.Personal – social : the child ability to get along with people and to take care of himself .

2. Fine – motor adaptive : the child ability to see and use his hands to pick up objects and to draw .

3. Language : the child ability to hear , to follow directions and to speak .

4. Gross – motor : the child ability to sit , walk and jump .

• It was performed on children from birth to 6 years .

• It has 105 items and the scoring is as follow : P = pass , F = failure , R = refusal , N.O. = no opportunity .

Bruininks – Oseretesky Test of Motor Proficiency (BOT)

• It is designed to assess gross and fine motor functions in children from 4.5 – 14.5 years . It included 8 subtests comprised of 46 separate items .

• The subtests are running speed & agility , balance , bilateral co-ordination , strength (gross – motor skills) , limb co-ordination (gross and fine motor skills ) , response speed , visual motor control , upper limb speed and dexterity ( fine motor skills) .

• Development depends on the maturation of the C.N.S.

• Mylination of C.N.S. Is complete by the end of the first year of age.

• Mylination without skills→→ Retardation

• Skills without mylination →→no function

Patterns of development

1st pattern of development

• A cephalocaudal direction or from head to tail. The head of the fetus initially forms more completely than the body and limbs. Then the trunk and limbs of the fetus develop. In following this pattern after birth, the infant develops beginning head control before learning to control the trunk or limbs functionally. Development moves downward with the child learning to control the upper trunk before the lower and using the eyes to engage the environment before learning the skills to use the hands to grasp and manipulate.

2nd pattern of development.

• From the center outward, or proximal to distal.

• The fetus develops the spinal cord and trunk , as limb buds are barely formed. As the fetus develops, the limb buds continue to grow into fully formed limbs and the peripheral nerves form to provide sensory data to the central nervous system, the brain.

• The infant follows the same patter of proximal to distal development, with the brain growth fastest in the first few years of life when the development of more fine control of limbs is still emerging. As the child grows, the movements of the limbs become more refined and the child develops specific skills, such as throwing, writing. And dancing

3rd Pattern of development

• From general to the specific,or from simple to more complex.

• As the fetus grows, undifferentiated cells migrate to specific location in the fetus and take on specific roles (brain cells, skin, blood). In the developing child, this pattern is also strong. The child learns general skills first; for example, the child will cry to communicate. General communication strategies are refined to specific language over time. Limb movements start out as gross patterns that are directed by reflexes, and mature into skilled movements that are functional for life and safety such as running, jumping and climbing.

Stages of growth and development

Prenatal Stage:

About 40 weeks (280 days), From conception

to birth . Infants born before the completion of 37

weeks of gestation are called premature infants

Embryonic Stage: The first 8 weeks of gestation

Fetal Stage : After 8 weeks of gestation to birth

Postnatal Stage:

• Neonatal Stage : From birth to 4 weeks of age

• Infant Stage : 4 weeks through 12 months of age

• Toddler : 13th months through 2 years of age

• Early childhood : From 2 years Through 6 years of age

• Middle childhood : From 6 years Through 12 years of age

• Adolescence : From 12 years of age up to 18 years.

Normal newborn baby

Characters of full term baby:

1. Should be delivered at or near term (after 40 weeks of pregnancy)

2. Free from any congenital defects or obstetrical changes.

3. Healthy pink color.

4. His or her heart rate is 100 -140 beats / min.

5. Breaths spontaneously and cries lustily

6. Position in prone lying, with head turned one side and arms, legs are flexed. (Flexion attitude).

7. On ventral suspension, no head control (head lag)

8. Has a skeletal muscle tone.

↑muscle tone in both upper and lower extremities due to unmylination

of the pyramidal tract.

9. The fist of the hands are clenched and the thumb inside the palm

Parameters of development

• Biological development is related to enzyme systems that stimulate complex metabolic changes.

• Psychological development refers to cognitive and effective ( emotional)

• Social development provides child to live in community.

• All the parameters of development affect one another.

Virginia Apgar’s method of evaluating newborn infant

Virginia Apgar’s method of evaluating newborn infant is now in standard use to evaluate the newborn infant one minute after birth. It’s useful to make serial Apgar scores: the longer the score remains low, the worse the prognosis with regard to mortality or neurological squeal.

|score |Heart rate |Respiratory effort |Reflex irritability |Muscle tone |Colour |

|2 |100 - 140 |Normal cry |Reflex irritability |Good |Pink |

|1 |100 |Irregular and shallow |Moderately depressed |Fair |Fair |

|0 |No beat |Apnoea for more than 60 sec |Absent |Flaccid |Cyanotic |

| |obtained | | | | |

Total score:

8 – 10 Good.

3 – 7 fair.

0 – 2 poor condition

Major theories of normal growth and development

The developmental changes that occur from birth to adulthood were largely ignored throughout much of history. Children were often viewed simply as small versions of adults and little attention was paid to the many advances in cognitive abilities, language usage, and physical growth. Interest in the field of child development began early in the 20th-century and tended to focus on abnormal behavior.

The following are just a few of the many theories of child development that have been proposed by theorists and researchers. More recent theories outline the developmental stages of children and identify the typical ages at which these growth milestones occur.

Child developmental theories:

Psychoanalytic theories (Sigmund and Erik Erikson)

Social developmental theories (Bowlby)

Cognitive theories (Jean Piaget)

Behavioral theories (Pavlov)

Psychoanalytic Theories

Sigmund Freud:

The theories proposed by Sigmund Freud stressed the importance of childhood events and experiences, but almost exclusively focus on mental disorders rather than normal functioning.

According to Freud, child development is described as a series of 'psychosexual stages.' In "Three Essays on Sexuality" (1915), Freud outlined these stages as oral, anal,, latency period, and genital. Each stage involves the satisfaction of a specific desire and can later play a role in adult personality.

Erik Erikson:

Theorist Erik Erikson also proposed a stage theory of development, but his theory encompassed development throughout the human lifespan.

Erikson believed that each stage of development is focused on overcoming a conflict. Success or failure in dealing with conflicts can impact overall functioning..

Behavioral Theories

Behavioral theories of development focus on how environmental interaction influences behavior and are based upon the theories of theorists such as Watson, Pavlov, and Skinner.

These theories deal only with observable behaviors. Development is considered a reaction to rewards, punishments, stimuli, and reinforcement.

Social Development Theories

There is a great deal of research on the social development of children.

John Bowbly proposed one of the earliest theories of social development. Bowlby believed that early relationships with caregivers play a major role in child development and continue to influence social relationships throughout life.

Cognitive theory:

Theorist Jean Piaget suggested that children think differently than adults and proposed a stage theory of cognitive development. He was the first to note that children play an active role in gaining knowledge of the world.

Piaget's Theory of Cognitive Development:

Jean Piaget believed that children go through a number of fixed stages on their way to independent thinking.

His theory on cognitive development, though, is perhaps the most widely accepted and most cited. 

Piaget believed that all children will go through the following stages in order, the age ranges are only a general guideline.

Each child matures in his own time, and even siblings don't do the same things at exactly the same age.

Sensory Motor Stage:

Birth to 2 Years

An enormous amount of growth and development takes place in the first two years of life. During that time span, children go from being completely helpless to walking, talking, and to a degree, being able to make sense of the world around them.

One of the most important milestones that children achieve in their first few years, according to Piaget, is their mastery of "object permanency," or the ability to understand that even when a person or object is removed from their line of sight, it still exists.

Early on, children are only able to perceive things that are right in front of them, but as they mature, they understand that if a ball rolls under a chair and they can no longer see it, it still exists, under the chair.

This is an especially important understanding for children, helping them to have an increased sense of safety and security since they can now grasp the fact that when mum leaves the room, she hasn't disappeared, but will soon return.

Preoperational Stage:

2-7 Years

Once object permanency is achieved, children move onto this next stage, which is marked by a number of advancements.

Language skills develop rapidly, allowing kids to better express themselves.

Also, children in the preoperational stage are egocentric, meaning that they believe that everyone sees the world the way that they do, leaving no room for the perspectives of others.

For example, a child will sometimes cover their eyes so that they cannot see someone and make the assumption that the other person now cannot see them, either.

A major indicator of this stage is called conservation, or the ability to understand that quantity does not change just because shape changes.

For example, if you were to pour the same quantity of liquid into two separate glasses, one short and wide and the other tall and thin, younger children would insist that the taller glass holds more.

Children who have mastered the concept of conservation would be able to understand that the quantities are identical.

Piaget explained that the child's inability to yet grasp the concept is due to their capacity to focus on only one aspect of a problem at a time (centration), their tendency to take things at face value (appearance), and the fact that they see something only in its current condition (state).

They cannot yet understand that the wider with of the short glass compensates for the height of the taller one.

Concrete Operations Stage

7 to 11 Years

During the concrete operations stage, the centristic thought process is gradually replaced by the ability to consider a number of factors simultaneously, giving them the ability to solve increasingly complex problems.

Also, kids at this stage can now understand how to group like objects, even if they are not identical.

For example, they are able to see that apples, oranges, cherries, and bananas are all types of fruit; even they are not exactly the same.

Another important developmental advancement that occurs during this phase is seriation, the ability to place things in order according to size.

Children who have a mastery of this concept are able to take jars of varying heights and place them in order, tallest to shortest.

They still have some distinct limitations to their thinking process, however, especially when it comes to applying concepts that they are unfamiliar with.

While their understanding of the things that they have direct access to is strong, kids this age still have a tendency to lack understanding of things that they haven't personally seen, touched, heard, tasted, or smelled.

Formal Operations Stage

11 and Beyond

In the final phase of cognitive development, children hold a much broader understanding of the world around them and are able to think in abstract ways.

They are also able to hypothesizes possible outcomes to a given problem and then think of ways in which to test their theories. Children in the formal operations stage learn to use deductive reasoning to draw conclusions, which opens them up to a wider base of knowledge than ever before.

An example might be as follows:

A bear is a mammal. All mammals have fur. Therefore, a bear has fur.

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The first trimester

From conception through 12 weeks

The first trimester is a highly sensitive period in the development of the baby.

Harmful substances that are ingested can affect the normal growth and development of the fetus.

Conception through the 10th week is referred to as the embryonic period.

This is the critical period of time when all of the major organs and structures are forming.

From conception through 12 weeks

1) At 5th week:

The embryo is :

❑ About one-half inch long

❑ Weighs less than an ounce.

❑ Its brain, heart, lungs, eyes, ears, arms, and legs are forming.

2) At 8th week:

❑ The fingers are distinct

❑ The beginnings of all essential external and internal structures are present.

3) At 10th week:

the embryo is known as a fetus.

❑ The face has a human profile and all of the major organs have formed.

❑ It is now about 4 inches long and weighs about one ounce.

❑ The heartbeat can now be heard with a Doppler stethoscope and can also be easily seen on ultrasound examination.

❑ The kidneys have begun to secrete urine, which partly makes up the amniotic fluid

around the baby.

❑ Teeth buds are present in the gums.

The Second trimester

From 13 weeks through 28 weeks.

The second trimester

is a period of rapid growth for the fetus.

Sexual differentiation is beginning to show.

By the 16th week:

it is about 6 inches long

weighs about 5 ounces.

It moves about, swallows amniotic fluid,

and has periods of sleep and wakefulness.

The third trimester

From 29 weeks until delivery

.

The final trimester marks the period of final growth.

During the last month of pregnancy: the baby can gain as much as half a

pound a week.

The average baby will weigh about 7 ½ pounds,

The range at full term from 5 ½ pounds up to over 9 pounds!

Fetal movement during this period of time is a good indicator of fetal well being.

Stages of Motor Development In Infants and Young Children

Month One:

Gross Motor Skills Fine Motor Skills

Can lift chin slihtly Hands fisted/reflexive grasp

Head lag in ventral suspension

Flexion attitude in prone

lying position

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Month Two

Gross Motor Skills Fine Motor Skills

Wobbly head while sitting Swipes toys with hands

Head Lag

Head lag when pull to sit

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Three Month

Gross Motor Skill Fine Motor Skill

Holds head steady in sitting Hands open

Rolls back to side Grasps/holds an object

Puts weight on arms while on tummy. Hands play at midline

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Month Four

Gross Motor Skills Fine Motor Skills

Sits on propped arms Reaches with both arms/hands Rolls tummy to side Brings fingers/hands in mo

No head lag seen when pulled Squeeze grasp emerging

to sit

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Month Five

Gross Motor Skills Fine Motor Skills

Rolls tummy to back Reaches with good aim

Wiggles few feet forward Puts objects/toys in mouth

Pushes up with arms Picks up spoon or cup by handle

while on belly Starts grabbing feet

Sits propped on hands

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Month Six

Gross Motor Skills Fine Motor Skills

Sits briefly independently Reaches precisely and grasps objects

Sits in a highchair Transfers toys from hand to hand

Rolls over both ways Bangs a cup on a table.

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Month Seven

Gross Motor Skills Fine Motor Skills

Sits unsupported~30 seconds Crosses midline when reaching

Rocks on all fours Uses whole hand to rake in objects

Pivots in a circle while on tummy Thumb to finger grasp emerging

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Month Eight

Gross Motor Skills Fine Motor Skills

Transitions tummy to sit Bangs cubes together

Crawls forward Uses a three-fingered grasp

Reaches while on tummy

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Month Nine

Gross Motor Skills Fine Motor Skills

Transitions sit to tummy Uses thumb to index grasp (crude)

Pulls to stand while holding on Crude release of objects

Creeps on all fours Drops toys and objects

Stands while leaning on furniture Points index finger

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Month Ten

Gross Motor Skills Fine Motor Skills

Cruises along furniture Pokes with fingers

Stands unsupported briefly Uses thumb to index finger

grasp (precise)

Transfers from crawl to sit Stacks objects

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Month Eleven

Gross Motor Skills Fine Motor Skills

Stands unsupported Releases a cube at will

Walks with hands held Removes pegs from a pegboard

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Month Twelve

Gross Motor Skills Fine Motor Skills

First independent steps Puts objects in a container

Stands unsupported~12 seconds Releases an object precisely

Assumes/maintains kneeling Stacks two one-inch cubes

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Months Twelve-Fifteen

Gross Motor Skills Fine Motor Skills

Walks independently Throws objects

Creeps/climbs stairs Places rings on a peg

Tries to climb out of highchair Makes marks with crayon

Squats to play Holds large crayon in fisted grasp

Kneels Pulls large pop beads apart

Stoops and recovers Builds a 2 block tower

Months Fifteen-Eighteen

Gross Motor Skills Fine Motor Skills

Walks in circles/backwards Directional scribble using crayons

Walks up stairs with help Throws a ball

Balance reactions in standing Builds a 3-block tower

Scribbles spontaneously Midlinhuse(1stabilizes/1manipulates)

Tries to kick balls

Climbs on furniture

Pulls toy while walking

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Months Eighteen-Twenty-Four

Gross Motor Skills Fine Motor Skills

Runs Unwraps things

Jumps in place/off a step Strings large, one-inch beads

Pedals a tricycle Builds a 6-block tower

Kicks a stationary ball Holds crayon with thumb and

fingers

Walks up stairs independently Turns 2-3 pages at a time

Throws a ball overhand Imitates vertical stroke Propels “ride-on” toys forward

Months Twenty-Four-Thirty-Six(2-3 years old)

Gross Motor Skills Fine Motor Skills

Hops on one foot Turns pages one at a time

Walks up stairs alternating feet Builds a 9 block tower

Walks down stairs alternating feet Strings small ½ inch beads

Walks backward Unscrews lid of a jar

Balances on one foot briefly Imitates horizontal line,

cross circle

Throws overhand at a target Holds pencil in hand

instead of fist

Catches a rolled ball Makes snips with scissors

Throws a small ball 2 feet Unbuttons

Rides a tricycle using pedals Places pegs in a pegboard

Gait development

The prerequisite for Gait development:

• C.N.S. maturation.

• Adequate motor control.

• Adequate R.O.M.

• Muscle strength.

• Appropriate bone structure.

• Intact sensation.

The development of a motor pattern in walking depends on a combination of neurological, mechanical, cognitive, and perceptual factors.

Neurological factors

The basic neural organization and function used to excite locomotion is controlled by a central pattern generator located either in the spinal cord or brain stem.

Descending neural input activates the central pattern generator, while descending and peripheral input modify the output to adapt the execution of locomotion.

The central pattern generator organizes the activation and firing sequence of muscles During Gait.

Mechanical factors

• Rang of motion,

• muscle strength,

• bony structure of the lower limbs

affect the early pattern of walking.

NORMAL GAIT ANALYSIS

| | |

|SWING PHASE |STANCE PHASE |

| | |

|initial swing |heel strike |

|mid swing |foot flat |

|terminal swing |mid stance |

| |push off |

Phases of gait

The stance phase of gait can be broken down into 5 sections

Heel Contact: Begins when the heel of the subject leg comes in

contact with the ground

Foot Flat: Heel contact continues as the foot becomes flat

Mid-Stance: The subject leg then begins to move forward

Heel Off: The heel begins to lift off of the ground

Toe Off: The toe finally lifts off the ground

The swing phase of the gait can be broken down into 3 sections:

Toe Off: Begins when the toe of the subject leg is lifted off

the ground

Mid-Swing: Continues as the subject leg swings forward

Heel Contact: The heel of the subject leg makes contact with

the ground.

Determinants of walking

Step length:

The longitudinal distance between the two feet, it increases through out

childhood until growth is completed.

This parameter is closely related to change in height and leg length

Cadence:

The frequency of steps taken in a given amount of time (Steps / min), it gradually

decreases with age through out childhood. The most reduction between 1-2

years.

The duration of single limb in stance.

It is the length of time during which only one foot is on the ground during

the stance phase, if it increases, it implies a measure of increasing stability.

Walking velocity:

It is the rate of walking; it can be expressed as the product of step length

and cadence. It increases with age 1 to 7 years, but the rate of change

decreases from 4 to7.

The normal walking has five major attributes:

• Stability in stance.

• Sufficient foot clearance in swing.

• Appropriate preposition of the foot for contact.

• Adequate step length.

• Energy conservation.

Gait development

From birth to 9 months:

• Body fat of the infant rises from 12% to 25% of the body mass which causes infant to be relatively weak, with increasing age and mobility , fat content drops and muscle mass increases.

• At this age the infant's gait is characterized by, supported walking, wide abduction, external rotation, flexion hips and knees 35o, bow legs and an everted heel position.

• The postural control and development of the antigravity muscle strength are important to develop independent ambulation.

• Antigravity strength of hip flexors is built by kicking from supine position, while hip extensor strength begins from activities in prone position.

• The hip and knee extensors are built during rising from kneeling to standing position.

• By 8 months of age, the visual, proprioceptive and vestibular systems work together to bring the central mass of the body (COG) back to a stable position.

At age 12 months

• The infant's center of body mass (COG) is closer to the head and upper trunk, at the lower thoracic level, the ratio of body fat to muscle mass is still high, The base of support is wide for both structural and stability reasons, Medio-lateral stability is achieved, but antro-posterior stability is limited.

• The ambulation characterized by wide base, increased hip and knee flexion, full foot contact, initial contact in planter flexion, short stride length, increased cadence and a relative foot drop in swing phase.

-Less than 50% of children demonstrate heel strike on commencement of walking. Instead, the child lands with a flat foot.

-their cadence (steps per minute) is very high, with a slow walking speed and shortened step length, which is directly related to leg length and age.

-95% of children can squat to play on the floor without support. The ability to perform this task is present from the onset of walking.

At age of 18 months

• Because of decreased abduction and improved stability, the base of support is decreased, heel position remain everted, knee flexion begains to emerge during initial stance phase as a heel strike develops, the duration of stance phase remains prolonged and cadence is increased., the limb is straight and the range of hip abduction is no longer excessive.

- heel strike is present in the majority of children. In this age group, the arms are outstretched for balance.

- 80% of children can run . The difference between walking and running is the presence of a period of "non-support", when neither foot is in contact with the ground. However, at this age the running ---child has little control over walking speed or change in direction and falls are frequent. By two years, 97% of children are able to run.

From 2-3 years

- The center of body mass is closer to lower limbs, base of Support is narrower, hips and knees extension develop, heel eversion in weight bearing can still observed but decreasing, heel strike is present with knee flexion during early stance phase.

- 90% of children can 'walk on their tip-toes' .

However, walking on heels' is a more difficult task. Only 60% are able to perform this activity by 2 years.

- 50% of children can hop for a distance of three metres. This increases to 92% by five years.

From age 6-7 years

The gait patterns are fully mature, but time and distance variables continue to vary with age and stature. The heel position is neutral by age 7 years, the center of body mass is still higher than in the adult, at the level of 3rd lumber vertebra.

By six to seven years the majority of children can hop on one leg or both .

Normal Hearing Development

Prenatal stimulation:

• The human fetus possesses rudimentary hearing from 20 weeks of gestation. This hearing will develop and mature during the remainder of gestation. The fetus is able to hear sounds outside the mother’s body, although it is able to hear low-frequency sounds much better than high-frequency sound.

• Babies begin to hear in the last few months of pregnancy.

• Thus, when an infant emerges into the world, they are well equipped for hearing system, although some evidence exists that an infant's sensory threshold is higher than that of an adult (i.e. a stimulus must be louder to be heard by a newborn).

However, if a newborn child does not display the following , it may be a sign of a hearing problem:

1. Does not startle, move, cry or react in any way to unexpected loud noises.

2. Does not awaken to loud noises.

3. Does not turn his/her head in the direction of a parent's voice.

4. Does not freely imitate sound.

Hearing at the first two important years:

The first two year is the time during which hearing develops in children. It is important for parents to be able to recognize signs of a hearing problem as early as possible and seek medical attention if there are any concerns.

Here is a guide of signs of normal hearing development by age through the first 2 years of life:

From 1 to 3 Month:

• During this period , babies love to hear their parents voices.

• Babies seem to respond best to the female voice, the

one associated with comfort and food.

• Besides voices, infants enjoy listening to music and

are fascinated by the routine sounds of life as well.

From 4-7 Month

A baby's hearing is crucial to speech development. During this period , most babies begin to understand the fundamentals of communication through hearing and language. When younger, a baby understands meaning through the tone of voice, but now the infant is beginning to pick out the components of speech. Most infants at this age can hear and understand the different sounds a parent makes and the way words form sentences.

Normal Hearing development from 4 to 7 months will be as follow:

By 4 months of age a baby should:

· Move or react when someone speaks or in response to any noise

· Startle when there is a very loud noise

Startle to sudden or loud sounds. Begin to localize sounds with eyes or

head movements.

By 6 months:

• Interest in different sounds. Experiment with making own sounds. Seemingly recognise familiar voices.

By seven months a baby should:

• Turn his/her head towards a voice or a noise(when a parent calls even without being seen)

• Stir or move in response to a noise or voice

• Startle when there is a large sound.

By 9 months a baby should:

Turn his/her head to find out where a sound is coming from

• Turn around if a parent is calling from behind

• Stir or move in response to voice or any sound

• Startle when there is a very loud noise.

9-12 months:

• Babble. Begin to understand simple words such as "mommy" and "bye-bye". Begin to follow simple instructions.

At 12 months a baby should:

• Turn his/her head in all directions and show an interest in a person's voice or a particular sound.

• Repeat sounds that parents make.

• Startle in response to a loud noise.

At 12-18 months:

• Words begin to form from the babble. Can use around 20 words and understand around 50 words.

At 2 years:

• Can usually speak in simple sentences using a vocabulary of around 200-300 words. Enjoy being read to and can identify and name many things in picture books.

At 3-4 years:

• Use words and sentences to express needs, questions and feelings. Vocabulary, pronunciation and understanding improve markedly during these years.

Early speech and language milestones:

• Newborns can localize a sound to their right or left side shortly after being born and will turn their head or look in the direction of a sound. This works best with loud noises when your baby is awake and alert, but they should also be able to hear soft sounds. They can also begin to smile spontaneously and in response to someone by 1 month. Infants learn to recognize their parents by 1-2 1/2 months.

• Infants can imitate speech sounds by 3-6 months.

• Monosyllabic babbling, or making isolated sounds with vowels and consonants (ba, da, ga, goo, etc) usually begins by 4-8 months.

• Polysyllabic babbling, or repeating vowels and consonants (babababa, lalalalala, etc) usually begins by 5-9 months.

• Comprehending individual words (mommy, daddy, no) usually occurs by 6-10 months.

• By 5-10 months, most infants can say mama/dada nonspecifically, using the words as more than just a label for his parents.

• Many infants can follow a one step command with a gesture (for example, asking for an object and holding your hand out) by 6-9 months. He should be able to follow a one step command without a gesture by 7-11 months.

• The correct use of mama/dada as a label for a parent usually occurs by 7-12 months.

• The first word (other than mama/dada) is usually spoken by 9-14 months.

• By 10-15 months, he should be able to point to an object that he wants.

• Your child will be able to say 4-6 words (other than mama/dada and names of family members or pets) by 11-20 months.

• He should be able to follow a two step command without a gesture by 14-21 months.

• Two word combinations or sentences are used by 18-22 months and can include phrases like 'Want milk', 'More juice', etc.

• A vocabulary spurt leading to a 50+ word vocabulary occurs by 16-24 months.

Parents are usually the first ones to think that there is a problem with their child's motor, social, and/or speech and language development, and this parental concern should be enough to initiate furthur evaluation. In addition to a formal hearing test (for children with speech delays), neurological exam (which will look at your child's muscle tone, strenght, reflexes, coordination, etc), and developmental assessment by their Pediatrician, children with developmental delays should be referred to an early childhood intervention program (for children under 3), so that an evaluation can be initiated and a treatment plan developed, including physical therapy, occupational therapy and possible speech therapy. He may also need a referal to a Pediatric Neurologist and/or a Developmental Pediatrician for furthur evaluation and treatment.

In addition to the screening tests described above, your Pediatrician may be able to calculate your child's motor quotient (MQ), which is his motor age (his age as calculated by what milestones he has met) divided by his chronological age and multiplied by 100. A motor quotient above 70 is considered normal, and between 50-70 is suspicious and requires furthur evaluation, although it is probably normal, and below 50 is considered abnormal. For example, if your child is 12 months old and has just begun to pull to a stand (motor age of 9 months, the age when most children are pulling to a stand), his MQ would be (9/12)*100 or 75, which is probably normal. On the other hand, if he has just begun to roll over (motor age of 5 months), then his MQ is (5/12)*100 or 42 and this is probably abnormal.

| |

|Normal Hearing Development in Children |

|Hearing: The first two important years |

| |

|The first two year is the time during which hearing develops in children. It is important for parents to be able to recognize |

|signs of a hearing problem as early as possible and seek medical attention if there are any concerns. |

|Here is a guide of signs of normal hearing development by age through the first 2 years of life: |

| |

|By 4 months of age a baby should: |

|• Move or react when someone speaks or in response to any noise |

|• Startle when there is a very loud noise |

| |

|By seven months a baby should: |

|• Turn his/her head towards a voice or a noise(when a parent calls even without being seen) |

|• Stir or move in response to a noise or voice |

|• Startle when there is a large sound |

| |

|By 9 months a baby should: |

|• Turn his/her head to find out where a sound is coming from |

|• Turn around if a parent is calling from behind |

|• Stir or move in response to voice or any sound |

|• Startle when there is a very loud noise |

| |

|At 12 months a baby should: |

|• Turn his/her head in all directions and show an interest in a person's voice or a particular sound |

|• Repeat sounds that parents make |

|• Startle in response to a loud noise |

| |

|At 2 years of age a child should: |

|• Be able to point out a part of his body when asked without seeing that person's lips move |

|• Be able to point to the right picture when asked(for example: Where is the cat? Where is the bird?) |

|• Be able to do simple tasks like give you one of his/her toys when asked, without seeing that person's lips move. |

| |

|: |

| |

| |

| |

VISUAL DEVELOPMENT

|[pic] |[pic] |

In the early months of life,

the visual system is still maturing; it is not fully developed at birth (and is even less developed in the premature infant).

From birth to maturity,

The eye increases to three times its size at birth, and most of this growth is complete by age 3

one third of the eye's growth in diameter is in the first year of life.

Some knowledge of normal visual development is necessary if abnormalities are to be noted.

A premature infant:

The eyelids are not have fully separated;

The iris is not constrict or dilate; the aqueous drainage system may not be fully functional.

The choroid lacks pigment.

Retinal blood vessels are immature.

Optic nerve fibers may not be myelinized;

There is still a pupillary membrane and/or a hyaloid system.

Lack of ability to control light entering the eye; visual system is not ready to function.

At birth

The irises of infants may have a gray or bluish appearance; natural color develops as pigment forms.

The eyes' pupils are not able to dilate fully yet.

The curvature of the lens is nearly spherical.

The retina (especially the macula) is not fully developed.

The infant is moderately farsighted and has some degree of astigmatism.

Functional implications: The newborn has poor fixation ability, a very limited ability to discriminate color, limited visual fields, and an estimated visual acuity of somewhere between 20/200 and 20/400.

:

By 1 month:

The infant can follow a slowly moving black and white target intermittently to midline; he/she will blink at a light flash, may also intermittently follow faces (usually with the eyes and head both moving together).

Acuity is still poor (in the 20/200 to 20/400 range), and ocular movements may often be uncoordinated.

There is a preference for black and white designs.

By 2 months:

Brief fixation occurs sporadically, although ocular movements are still uncoordinated there may be attention to objects up to 6' away.

The infant follows vertical movements better than horizontal , and is beginning to be aware of colors (primarily red and yellow).

There is probably still a preference for black and white designs.

By 3 months:

Ocular movements are coordinated most of the time; attraction is to both black and white and colored (yellow and red) targets.

The infant is capable of glancing at smaller targets (as small as 1"), and is interested in faces; visual attention and visual searching begins.

The infant begins to associate visual stimuli and an event (e.g., the bottle and feeding).

By 4 months:

"Hand regard" occurs; there is marked interest in the infant's own hands.

He/she is beginning to shift gaze, and reacts (usually smiles) to familiar faces.

He/she is able to follow a visual target the size of a finger puppet past midline, and can track horizontally, vertically, and in a circle. Visual acuity may be in the 20/200 to 20/300 range

By 5 months:

The infant is able to look at (visually examine) an object in his/her own hands; ocular movement although still uncoordinated at times, is smoother.

The infant is visually aware of the environment ("explores" visually), and can shift gaze from near to far easily; he/she can "study" objects visually at near point, and can converge the eyes to do so; can fixate at 3.

Eye-hand coordination (reach) is usually achieved by now.

By 6 months:

Acuity is 20/200 or better, but eye movements are coordinated and smooth; vision can be used efficiently at both near point and distance.

The child recognizes and differentiates faces , and can reach for and grasp a visual target.

Hand movements are monitored visually; has visually directed reach." May be interested in watching falling objects, and usually fixates on where the object disappears.

Between 6 and 9 months:

Acuity improves rapidly (to near normal);

"explores" visually (examines objects in hands visually, and watches what is going on around him/her).

Can transfer objects from hand to hand, and may be interested in geometric patterns.

Between 9 months and a year:

The child can visually spot a small (2-3mm) object nearby;

Watches faces and tries to imitate expressions;

Searches for hidden objects after observing the "hiding;“

Visually alert to new people, objects, surroundings;

Can differentiate between known and unfamiliar people; vision motivates and monitors movement towards a desired object.

By 1 year:

• Both near and distant acuities are good (in the 20/50 range); there may be some mild farsightedness, but there is ability to focus, accommodate (shift between far and near vision tasks), and the child has depth perception;

• He/She can discriminate between simple geometric forms (circle, triangle, square), scribbles with a crayon, and is visually interested in pictures.

• Vision lures the child into the environment. Can track across a 180 degree arc.

By 2 years:

• Myelinization of the optic nerve is completed. There is vertical (upright) orientation; all optical skills are smooth and well coordinated.

• Acuity is 20/20 to 20/30 (normal).

• The child can imitate movements, can match same objects by single properties (color, shape), and can point to specific pictures in a book.

By 3 years:

• Retinal tissue is mature.

• The child can complete a simple form board correctly (based on visual memory),

• Can do simple puzzles, can draw a crude circle, and can put 1" things into holes.

Social and Emotional Development

Social and emotional development means:

▪ The development of emotional communication.

▪ Understanding of self, ability to manage one's feelings .

▪ Understanding and knowledge of other people.

▪ Relationships, interpersonal skills and moral behavior.

Emotional Development Importance:

▪ Emotions are central in all aspects of human activity.

▪ They are vital to cognitive development because emotional reactions lead to learning that is essential for survival.

▪ It is also vital to social behavior because babies' emotional reactions like crying, laughing and smiling affect others' interests in powerful ways.

▪ Similarly the emotional reactions of others regulate children's social behavior.

▪ Much research indicates that emotions influence children's physical well-being.

▪ Constant psychological stress in children is associated with various health difficulties.

▪ Emotions are also important in the emergence of self-awareness.

▪ Infants can not describe their feelings as adults do . So, they use emotions to communicate.

▪ In addition to facial expressions, some body movements also provide information .

▪ International studies have suggested that infants from various cultures show almost the same facial expressions.

▪ In the initial 2 years of life, babies and toddlers show basic emotions like happiness, sadness, anger and fear.

▪ Basic emotions are so universal that even non-human primates display them.

[pic][pic]

▪ Beside basic emotions, human beings are capable of another set of emotions called the self-conscious emotions.

▪ As the name implies, these emotions include shame, pride, embarrassment, guilt and envy.

Birth - 6 months:

▪ Show signs of almost all basic emotions.

▪ Smiles socially and laughs.

▪ Express happiness more when interacting with familiar people.

▪ Matches adults' emotional expressions while communicating face-to-face

▪ Develops awareness of self as a knower and actor; like understanding that self is separate from rest of the world.

[pic]

7 – 12 months

▪ Anger and fear increase, especially the case of anxiety.

▪ They feel secure with caregiver and builds strong caregiver relationship.

▪ Babies can detect the meaning of others‘ emotional signals .

▪ They feel much attached to familiar caregivers.

13 - 18 months

▪ Can play with familiar adults and children.

▪ Develops awareness of self as an object of knowledge and evaluation, like understanding the psychological and social characteristics of self.

▪ Understands that others' emotional reactions may differ from one's own.

▪ Can start feeling empathy.

19 - 24 months

▪ Display self conscious emotions but the intensity depends on monitoring

▪ and encouragement of adults.

▪ Adds more words in the vocabulary for talking about feelings.

▪ Learns to tolerate absence of familiar caregiver.

▪ Can use words to describe peer's behaviors.

▪ Learns to use own name or personal pronouns to describe self.

▪ Can sort others into categories based on age, sex, and other characteristics.

▪ Starts to develop self control.

2 - 3 Years

▪ Begins to develop self concept and self esteem.

▪ Understands causes, effects and behavioral signs of basic emotions.

▪ Learns to cooperate.

▪ Empathy increases.

3 - 4 Years

▪ Improves emotional self-regulation.

▪ Decreases non-social activities and plays interactively more.

▪ Forms first friendship.

▪ Begins to prefer same-sex playmates.

▪ Improves ability to interpret, predict and influence others' emotional reactions.

▪ Expresses empathy more by language.

▪ Solves social problems better.

▪ Knows many morally relevant rules and behaviors.

5 – 6 Years

▪ Improves ability to interpret, predict and influence others' emotional reactions.

▪ Expresses empathy more by language.

▪ Solves social problems better.

▪ Knows many morally relevant rules and behaviors.

Denver II Developmental Screening Test Handout

 

DENVER II DEVELOPMENTAL SCREENING TEST

Handout Written by: Dr. Frances Murphy

 

The Denver II Developmental Screening Test “…is designed to be used with apparently well children between birth and 6 years….”

 

Objectives:

♦    Study test and administration of test

♦    Calculate and record age line

♦    Identify portion of test which to begin

♦    Identify pass/fail criteria

♦    Rate child’s behavior during test

♦    Identify scores

♦    Interpret test results

 

Not an IQ test – 126 tasks/items:

1. Personal-Social: getting along with people and caring for personal needs

2. Fine Motor-Adaptive: eye-hand coordination, manipulation of small objects and problem-solving

3. Language: hearing, understanding, and using language

4. Gross Motor: sitting, walking, jumping, and overall large muscle movement

 

Applications:

♦    Provides an organized, clinical impression of a child’s overall development

♦    Alerts regarding the potential for developmental difficulties

♦    Provides comparisons with other children

♦    Not recommended as a predictor of later development

 

Draw age line from top to bottom of page –

Date of test - ___ month ___ day ______ year (Remember – if you have

Date of birth - ____ month ___ day ______ year to ‘borrow’, 30 days = month;

Difference _________________________________ 12 months = year)

equals exact age ____ months___ days______ years

 

In each sector, administer

•      3 items nearest to and left of age line

•      all items on (intersecting) the age line

•      continue until 3 ‘fails’ occur

 

Three trials are allowed to perform each item

 

After test, record Test Behavior Rating

 

Item Scoring:

“P” for PASS, the child successfully performs or the caregiver reports (as appropriate)

“F” for FAIL, the child does not successfully perform an item or the caregiver reports so

“N.O.” for NO OPPORTUNITY (this is used on “report” items only)

“R” for REFUSAL, the child refuses to attempt item (cannot be used on report “items”)

 

|Interpretation: |Be Familiar with the Criteria |Determine Results: |

|♦    Advanced |♦    Instruct the child with the words |♦    Normal: no delays and maximum of 1 caution |

|♦    Normal |♦    from the manual |♦    Suspect: 2 or more cautions and 1 or more |

|♦    Caution |♦    Observe the standards indicated for P/F |delays |

|♦    Delayed |♦    Remember that 3 trials may be given |  |

|♦    No Opportunity | |  |

|  | | |

|  | | |

 

Developmental Delays

Parents are often have concerns about their children's development, especially when they see other children of the same age who have already attained a milestone that their child still hasn't met, causing them to think that their child is 'slow' or 'seems behind.' It is important to keep in mind that for each milestone, there is a range of ages during which a child will normally meet it. For example, some children may walk as early as 11 months, while others may not walk until they are 15 months old, and it is still concerned normal.

Developmental milestones are determined by the average age at which children attain each skill, therefore, statistically, about 3% of children will not meet them on time, but only about 15-20% of these children will actually have abnormal development. The rest will eventually develop normally over time, although a little later than expected.

Be sure to bring up any concerns that you have about your child's development with your Pediatrician, especially if he seems to be losing milestones, or not doing things that he was able to previously do.

A developmental delay occurs when your child has the delayed achievement of one or more of his milestones. This may affect your child's speech and language, his fine and gross motor skills, and/or his personal and social skills.

Your Pediatrician should screen for delays at your child's well child visits. This may consist of simple questions to see what your child is able to do at different ages, or it may include a formal screening test, such as the Denver II Developmental Screening Test. The Denver test can look for delays in your child's social and personal skills, fine and gross motor skills and language.

Developmental delays, especially if they involve a language delay which may be secondary to a hearing loss, should be identified as early as possible.

A child with a global delay will have delays in all areas of development. It is usually caused by a static (does not worsen with time) encephalopathy caused by a disorder before or near the time or birth. Causes of global delays include prematurity, cerebral malformations, chromosomal disorders, infections, and progressive (may worsen with time) encephalopathies (metabolic diseases, hypothyroidism, neurocutaneous syndromes (neurofibromatosis, tuberous sclerosis), Rett syndrome, and hydrocephalus). Testing to look for the cause of a global developmental delay may include a head MRI.

Some signs that your infant may not be meeting his normal motor milestones include not being able to bring his hands together by 4 months, not rolling over by 6 months, having head lag when pulled to a sitting position after 6 months, not sitting by himself without support by 8 months, not crawling by 12 months, and not walking by 15 months. Remember that mild delays in motor development can be normal, and there is a range during which these milestones are usually met, so your child may not meet each one at the same time as other children. Delayed motor

development, with normal language skills, can be caused by a neuromuscular disorder or mild cerebral palsy.

A delay in fine motor skills in older children may be manifested by not being able to use a spoon or fork, tie his shoes, button his clothes, write his name, draw shapes, color inside the lines, or hold a pencil correctly at the age appropriate time, or by having poor handwriting. A delay in gross motor skills in older children may include not being able to ride a tricycle or bicycle, being clumsy, or not walking correctly.

The early speech and language milestones which are listed below include the upper limit of when 75% of infants meet this milestone, so your child may still be developing normally if he has not mastered a milestone by the age indicated. These milestones should be used as a general guideline to help identify infants that are at risk for having speech and language problems so that their development can be watched closely. Among the screening tests available that your Pediatrician may perform are the Early Language Milestone (ELM) Scale-2 and the Clinical Linguistic and Auditory Milestone Scale (CLAMS). Delayed speech and language development can be caused by a developmental language disorders (DLD), hearing loss, mental retardation and autism.

Early speech and language milestones:

• Newborns can localize a sound to their right or left side shortly after being born and will turn their head or look in the direction of a sound. This works best with loud noises when your baby is awake and alert, but they should also be able to hear soft sounds. They can also begin to smile spontaneously and in response to someone by 1 month. Infants learn to recognize their parents by 1-2 1/2 months.

• Infants can imitate speech sounds by 3-6 months.

• Monosyllabic babbling, or making isolated sounds with vowels and consonants (ba, da, ga, goo, etc) usually begins by 4-8 months.

• Polysyllabic babbling, or repeating vowels and consonants (babababa, lalalalala, etc) usually begins by 5-9 months.

• Comprehending individual words (mommy, daddy, no) usually occurs by 6-10 months.

• By 5-10 months, most infants can say mama/dada nonspecifically, using the words as more than just a label for his parents.

• Many infants can follow a one step command with a gesture (for example, asking for an object and holding your hand out) by 6-9 months. He should be able to follow a one step command without a gesture by 7-11 months.

• The correct use of mama/dada as a label for a parent usually occurs by 7-12 months.

• The first word (other than mama/dada) is usually spoken by 9-14 months.

• By 10-15 months, he should be able to point to an object that he wants.

• Your child will be able to say 4-6 words (other than mama/dada and names of family members or pets) by 11-20 months.

• He should be able to follow a two step command without a gesture by 14-21 months.

• Two word combinations or sentences are used by 18-22 months and can include phrases like 'Want milk', 'More juice', etc.

• A vocabulary spurt leading to a 50+ word vocabulary occurs by 16-24 months.

Parents are usually the first ones to think that there is a problem with their child's motor, social, and/or speech and language development, and this parental concern should be enough to initiate furthur evaluation. In addition to a formal hearing test (for children with speech delays), neurological exam (which will look at your child's muscle tone, strenght, reflexes, coordination, etc), and developmental assessment by their Pediatrician, children with developmental delays should be referred to an early childhood intervention program (for children under 3), so that an evaluation can be initiated and a treatment plan developed, including physical therapy, occupational therapy and possible speech therapy. He may also need a referal to a Pediatric Neurologist and/or a Developmental Pediatrician for furthur evaluation and treatment.

In addition to the screening tests described above, your Pediatrician may be able to calculate your child's motor quotient (MQ), which is his motor age (his age as calculated by what milestones he has met) divided by his chronological age and multiplied by 100. A motor quotient above 70 is considered normal, and between 50-70 is suspicious and requires furthur evaluation, although it is probably normal, and below 50 is considered abnormal. For example, if your child is 12 months old and has just begun to pull to a stand (motor age of 9 months, the age when most children are pulling to a stand), his MQ would be (9/12)*100 or 75, which is probably normal. On the other hand, if he has just begun to roll over (motor age of 5 months), then his MQ is (5/12)*100 or 42 and this is probably abnormal.

THE COMMON FACILITATORY AND INHIBITORY TREATMENT TECHNIQUES

It is of great challenge for physical therapist to select methods most efficient for each patient's needs. Appropriate selection of the treatment methods depends upon the understanding of many aspects, such as:

1) The neuro-physiological bases of each method.

2) The biomechanical influencing of the treated body part(s), segment(s), or body as a whole on the applied method, and the mechanical effect of the intervention on the treated part.

3) The nature of pathology and symptoms affecting the patient's activity.

4) The individual characters of each patient.

To initiate a movement response we should try to increase the neuronal activity

(it refers as facilitation) or to decrease the capacity to initiate a movement response

we should try to decrease the neuronal activity (it refers as inhibition)

The sensory stimulation technique can be used separately or grouped according to the receptors activated, the nature of stimulation (intensity, duration and frequency) need to be adjusted and readjusted to meet the individual needs of the patient.

The techniques commonly used are classified according to the type of sensory receptors activated.

The common facilitatory techniques are:

Proprioceptive stimulation techniques.

Extroceptive stimulation techniques.

Vestibular stimulation techniques.

Special senses ( vision, hearing, smell and taste ) stimulation techniques.

Multi-sensory stimulation techniques.

Autonomic nervous system stimulation techniques.

Proprioceptive stimulation techniques:

a) Stretch: May be applied in three ways; quick, prolonged, and maintained

stretch.

Application of this technique may include tapping which is commonly used in three forms; on tendon, on muscle belly and with the use of gravity. It is used in preceding passive movement.

• The quick stretch produce a relatively short lived contraction of the agonist muscle and short lived inhibition of the antagonist muscle.

• Prolonged and firm stretch produces inhibition of muscle responses which may help in reducing hypertonus, e.g. Bobath's neuro-developmental technique, inhibitory splinting and casting technique.

• The maintained stretch, resistance can be applied manually or mechanically or by using of gravity and body weight. Resistance facilitates muscle contraction which is directly proportional to the amount of resistance applied. Improving kinesthetic awareness and increasing strength are another two benefits gained from resistance.

b) Vibration:May be applied in two ways; high and low frequency.

• The high frequency vibration is driven from vibratorthat optimally operates at a frequency of 100 – 200 Hz and at amplitude of 1 – 2 mA. This type of vibration produce facilitation of muscle contraction through what is known as tonic vibration reflex. This facilitatory effect sustained for a brief time after application. Therefore it can be used for stimulating muscles whose primary function is one of tonic holding.

• The low frequency stimulation 5 -50 Hz has an inhibitory effect on muscle through its activation of spindle secondary endings and golgi tendon organs.

C) Approximation or compression of the joint surfaces:

facilitates posture extensors which are needed to stabilize the body.

• Approximation can be applied slowly to inhibit muscle control or in jerky manner to facilitate muscle control.

• The application may be manually and/or by using weight bearing postures.

Joint awareness may be improved by approximation which will lead to

enhancing motor control.

c) A firm and moderate inhibitory pressure on tendons:

may result in inhibition of muscle control.

• It can be applied manually and/or through devices such as splints.

• Positioning may be used to achieve an inhibitory pressure, e.g. quadruped position to inhibit the quadriceps muscle and the long finger flexors of the hand.

Exteroceptive stimulation technique

a) Touch:

Is one of the simple ways of facilitation of muscle activity by eliciting the

phasic, protective withdrawal reflexes.

• This reaction maintained for several seconds after discharge.

• The location of the stimulus and its intensity play the important role in the magnitude of reaction.

• Application of the touch m can be manually using brief, light stroke, brief swipe ice cube, noxious stimulus and/or light pinching.

b) Brushing:

As a therapeutic technique presented originally by Margeret Rood to

facilitate movement responses.

• Application can be manually or by using battery-operated brush.

• Skin overlying muscle can facilitate it and enhances static holding postural extensors and will have immediate and long latency responses.

c) Icing for a long period:

(more than 20 min0 can inhibit muscle activity, postural tone (locally).

• Application of the prolonged ice can be used clinically by four types; ice chips, ice wraps, ice pack and immersion in cold water.

d) Neutral warmth:

It is one of the most common way to inhibit postural tone and muscle

activity.

• It acts through stimulating the thermo receptors and activating of parasympathetic responses.

• Usually 10-20 minutes are sufficient period to produce effect.

• The application may be by wrapping body part with towels, hot packs, tepid baths and air splints.

e) Maintained touch:

It can be used to produce a general calming effect and generalized inhibition.

• Firm manual contacts (pressure0 to midline abdomen, back are the common used techniques.

f) Slow stroking:

It Is another technique used to produce a generalized calming effect by

activation of ANS.

• It may be applied by using a flat hand over the paravertebral muscles from cervical to sacral regions.

• The generally calming effect can decrease muscle tone.

• 3-5 minutes are a sufficient period to produce effect.

g) Manual contact:

Itis one of the most success technique to facilitate motor control.

A manual direct firm contact over the desired muscles is the used technique.

Vestibular Stimulation Technique

• The vestibular stimulation technique is a proprioceptive unique sensory system with multi-sensory function.

• According to the type of stimulus we can use the vestibular system to achieve many treatment alternatives.

• Total body inhibition can be achieved by slow rocking, slow anterior-posterior movement, slow horizontal movement, slow vertical movement and slow linear movement.

• Total body facilitation can be achieved by rolling patterns, a rocking pattern on elbows and extended elbows and crawling.

• Also spinning induces tonal responses and causes a strong facilitation of movement through the overflow of impulses to higher centers.

• A facilitation of postural extensors is another effect of vestibular stimulation if it is used by a rapid way anterior-posterior or angular acceleration of the head and body while the child in prone position.

• The inverted position is commonly used now to achieve a total body inhibition, while it may be used to increase to in certain extensors.

Special Senses Stimulation technique

Visual system:

May be used to produce a decrease or an increase in firing of sensory afferent fibers and have an overall effect on CNS excitation.

Cool colors, a darkened room and monotone color schemes all tend to have an inhibitory effect on muscle tone, a calming mood and generalized inhibitory response.

On the other hand a facilitatory effect can be gained by intermittent visual stimuli, bright colors, bright light and a random color scheme.

If the sensory component of the tactile, proprioceptive or vestibular system has been lost or severely damaged the visual stimulus may consider an effective alternative.

Auditory system stimulation :

As a treatment technique depends on the quality, quantity and effect of voice.

The therapist's voice can be considered a very important therapeutic tool to produce a facilitatory or inhibitory response on muscle tone and activity.

The same effect may be gained by music.

Auditory biofeedback is a very important and famous therapeutic modality which depends on intact auditory system.

Olfactory system :

May be used as a treatment modality especially during feeding procedures.

Some odors such as vanilia and banana may be used to facilitate sucking movement.

Withdrawal patterns can be facilitated with ammonia and vineger.

Therapist should use olfactory system as a treatment technique under restricted precautions because its arousal and emotional effect.

Multi-Sensory Treatment Techniques

Multi-Sensory Treatment Techniques is the most common type of procedures used by therapists, who may concentrate on one target but more than one or two sensorysystems will work simultaneously. For example, tapping is akind of stimulation primarily can consider as a proprioceptive in origin but exteroceptive sense will work automatically.

So facilitation of muscle activity will originate from two origins the proprioceptive stimulus through the afferent activity within the muscle spindle and the reflemechanism coming from the tactile receptors.

Another example, any exercise including head and body movements in space

The vestibular system and proprioceptive receptors will be fired simultaneously and influencing the muscle activity.

Also, when therapist talk to the patient and demonstrate the exercise for him by any means or correct his performance, this means are auditory, visual, vestibular, tactile and proprioceptive stimulation working together.

Autonomic nervous system stimulation technique

Study of the interconnections between the ANS and CNS have lead the clinicians

and therapist to know viable treatment approaches that depend on both systems.

Both systems must react and work in integrated manner at appropriate intensities.

should- according to that – differentiate between hypertonicity and disturb

movement created by emotional stresses which may lead to ANS reaction

versus disorders resulting from CNS damage.

There are four treatment procedures can be used to affect on movement and muscle one throughout ANS reaction which normally produce a parasympathetic response:

1) Slow stroking over the paravertebral areas will cause inhibition.

2) Inverted tonic labyrinthine therapy.

3) Slow, smooth, passive movement within pain free range.

4) Maintained deep pressure on the abdomen, palms, soles of the feet, peroneal area, and

skin rostral to the top lip may cause a reduction of tone or hyperactivity.

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