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Early Identification and Treatment For Babies with High Risk of Neurological Impairment

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Aim

To understand the importance of primitive reflex in early identification and to know the intervention techniques

Objectives

To Know the Incidence level. To know the Developmental Profile. To know about Primitive reflexes. To know the Pointers to CNS Insult. To understand the Treatment principles.

Incidence
Children with neurological impairment is not completely preventable as in other childhood diseases like Poliomyelitis, Smallpox etc. The incidence of Cerebral Palsy in undeveloped areas of the world, where infant mortality is very high, is the same as in northern Europe, where infant mortality is the lowest. It also explains why modern obstetrical care, including monitoring and a high rate of Cesarian section, has lowered infant mortality rates but not the incidence of cerebral palsy. This gives a message that preventing completely is likely not possible.

Incidence
One important reason again goes to modern developments in Medicine, where premature babies and high risk babies are now able to survive, with some babies compromised with their nervous system. Also it throws light on the tunnel vision of hypoxic brain damage as a primary reason for brain injury. There are many genetic causes still undiscovered.

Since complete prevention is still very difficult, there is a lot of emphasis now given to early identification.

Neuroanatomi- Postural Reflex Motor cal structures Development Development

Cortex

Equilibrium Reactions Righting Reactions

Voluntary Control

Midbrain

Excitatory & Inhibitory Control

Brainstem/ Spinal Cord

Primitive Reflexes

Stretch Reflexes

The Developmental Profile


Sophisticated Cortex Primitive Cortex Early Cortex Initial Cortex Mid Brain Pons Medulla and spinal Cord

The Developmental Profile


Sophisticated cortex Using a leg in a skilled role which is consistent with the dominant hemi Walking and running in cross patterns Walking with arms freed from the primary balance role Walking with arms used in a primary balance role

Primitive Cortex Early Cortex

Initial Cortex

The Developmental Profile


Midbrain Creeping on hands and knees (cross pattern)

Pons
Medulla and cord

Crawling in the prone position(cross pattern)


Movements controlled by primitive reflexes

Role of Primitive Reflex in Development


The above profile tells us that when the baby is born the CNS is not fully matured. The tone, posture and movements are under the unopposed control of the lower centers of the CNS. The baby is influenced by primitive/postural reflexes. The body responds mechanically and automatically to a no. of influences, such as head or body position. The baby at birth is motorically at a primitive, crude level, a reflex level. The movements are automatic with no component of voluntary control or meaningful direction.

Role of Primitive Reflex in Development


The baby is in physiological flexion at birth, the primitive reflex are responsible for introducing extension in pro-gravity as well as antigravity position. As the nervous system develops, higher level postural reactions starts developing and the primitive reflexes gets integrated. This blending, creates a smooth, coordinated patterns of movement that are efficiently executed to perform highly skilled activities.

Early Identification
Can be made
Clinically examining the primitive reflexes
Going by the development of the Baby With C.T (computerized Tomography) Scans and M.R.I studies. All the above has to be matched with the prenatal and birth histroy.

Early Identification
The evaluation of pathological motor development had remained the source of diagnosis in the early 80s. A standardized classification for the various symptoms and neuromuscular reactivity had not been available. It was Vojta who developed a standardized diagnostic procedure through which it is possible to detect the development of neurological impairment in early stages of life.

Early Identification-VOJTA BASIS


The common basis for classification, according to vojta, is the ability of the central nervous system to react appropriately to postural changes. For this purposes, vojta has chosen 7 postural reflexes that inform us about the quality and extend of neurological development from the newborn period until upright coordinated walking is possible:

Early Identification-Vojtas Reaction


The traction reaction The landau reaction The axillary suspension reaction The vojtas side-tilt reaction The collis horizontal suspension reaction The peipers and isberts vertical suspension reaction The collis vertical suspension reaction

Early Identification
One may not diagnose cerebral palsy in the first 6 months of life. However with the help of postural reflexes, it is possible to diagnose a reduction of the ability to regulate automatically the bodys position in space. Vojta has created a diagnostic category for this inability: disturbance of central coordination. This is not an etiological diagnosis. Neurological impairment may develop from a disturbance of central coordination, but not necessarily.

Early Identification
It is always noted the same stereotypical abnormal patterns in a case of disturbed central coordination. Such pattern are similar to the fixed pathological patterns of fully developed children with cerebral palsy. Eg. Rigid extension or rigid flexion of the arms with retraction of shoulders and clenched fists;

Early Identification
Opisthotonos or extreme hypotonicity of the trunk. Rigid extension combined with adduction of the legs.

Baby with Normal patterns and Stereotypical patterns

Early Identification
Grading a disturbance of central coordination has proven very important for clinical practice. The gradation is based on the thesis that the more the brains coordination ability is disturbed, the greater the number of abnormal postural reactions will be.

Pointers to CNS Insult


Grading Central coordination

Mildest 1,2 or 3 Reactions abnormal

Mild 4 0r 5 reactions abnormal

Moderate 6 or 7 Reactions abnormal

Severe- more than seven Reactions abnormal

Pointers to CNS Insult


This understanding will help us to know how to identify a new born baby with high risk. Further as their basic function is survival, if they are suppressed or absent it is a pointer to an insult to the CNS. These reflexes has to be integrated at a certain period of time, if they are present beyond the normal time it again is a pointer to insult to the CNS.

Early Intervention
Early intervention aims at giving normal sensorymotor feedback for normal development. Persistence of primitive reflexes blocks the development of higher level reactions. So early intervention techniques focuses on inhibiting abnormal reflexes and facilitating normal reactions. Which can be done with the activities of daily living.

Early Intervention Techniques


Positioning
Nest Positioning Hammock

Handling
Lifting Carrying Feeding Dressing

Sensori-motor Intervention
Lap Treatment Vestibular Stimulation

Positioning
Proper Positioning of the child is essential to ensure the appropriate environment which enhances the psychomotor and sensori-motor development. The child can be positioned in supine, prone and side lying.

Positioning Goals
FLEXION To facilitate midline orientation & develop body image. To endorse ventral muscle activity. Facilitate stability in longitudinal axis of the body. Enable and stimulate activity of diaphragm. Facilitate respiration and feeding reactions. Promote spontaneous activity of the child and to give him the chance to practice and strengthen physiological postural and movement patterns.

Positioning in different positions


In Supine, a nest is build with the help of a towel or a u-shaped pillows, the baby can safely and comfortably be brought into flexion. The child feels safe as she is safely surrounded by comfortable material. She can feel her body and relate to her dimensions.

Positioning in Side lying


In side lying, the pillow/towel snuggles like a half moon against the back, between legs and against the chest. This way, the child experiences containment and thus security and stabilization in a flexed position.

Positioning in Prone Lying


In prone a towel is rolled and placed under the sternum to avoid retraction of the arms and to offer the possibility of a slight weight-bearing on the forearms.

HANDLING
Handling is the carry-over from treatment to everyday life. While being handled i.e, being dressed, undressed, picked up, carried, fed etc., the child has to adjust to being moved. Depending on the degree of the impairment ,the child can either participate or is totally dependent on the caretaker. .

Handling
Handling will have a direct influence on tone and movement. Hence ,it is crucial that handling is related to treatment;
To facilitate active and normal participation. To inhibit abnormal reactions and responses to being handled.

Child carried with minimal support

Promoting Sitting with Head in Midline

SENSORIMOTOR INTERVENTION
The foremost goals of sensorimotor intervention are to help the child deal with mass of different, strange and often unpleasant, if not frightening stimuli. To develop the best possible intervention between child and parents/ caregivers as well as to offer the opportunity of experiencing normal postural and movement patterns.

SENSORIMOTOR INTERVENTION
The aim is to achieve a calm and alert state to let the child experience normal movement as well as visual and auditory interaction. This normal movements, for ex, consists of hand-hand/ hand-mouth contact, free movement of the limbs and positioning of the head and trunk in midline. This can be achieved either on the lap or on the floor.

Lap Treatment

Promoting Midline Activities on the Floor

VESTIBULAR STIMULATION (ROCKING)


Abnormalities of movement and behaviour may be positively influenced through graded vestibular stimulation. When the child is put into a towel, with the limbs in mid position, flexion and H/H, H/M co-ordination are promoted whilst jittery and unorganized movements are inhibited. This vestibular stimulation can be done in a towel or in hands of the therapist or caregivers.

Vestibular Stimulation

Carry-over
Carry over of treatment is very important in early intervention, which can be achieved only by involving parents or caregivers in therapy.

Involving Parents in Therapy Child Walking Independently in a Parallel Bar

Child transferring from the Balance Board to a Stool

Conclusion
Since Early Intervention is Very important for babies with high risk for neurological impairment, its very important to identify these babies as early as possible, to maximize their potential to the maximum.