early assessment and intervention - university of …...hadders-algra; the neuronal group selection...
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S A M E E R R A H I M P H Y S I O T H E R A P I S T
R C W M C H
S A M E E R . R A H I M @ W E S T E R N C A P E . G O V . Z A
Early Assessment and Intervention
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What is early intervention
Developmental theories
Impact of primitive reflexes on early development
Assessment tools
Learning acquired in youth is an inscription in
stone…” Old Indian Proverb
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Early Intervention
Birth – 5 yrs old
Promote child health
Enhance emergence of competencies
Prevent developmental delay
Remediate existing or emerging disabilities
Prevent functional deterioration
Individualized developmental and therapeutic programs
Mutually planned with family and caregivers
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Early Intervention
When?
Where?
How?
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Early Intervention- When?
EARLY IN LIFE
Brain plasticity
Highest at 6-8 months post term
No specific disorder
Poor goal setting
EARLY IN EXPRESSION OF DISORDER
Usually later in life
Dysfunction is identified
Can work towards specific goals
Relatively late wrt Plasticity
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Early Intervention- Where
Where to start
NICU
Stress reduction
Parent child interaction
Passive handling
General developmental stimulation
Ward
Discharge home
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Early Intervention How?
Tailoring of intervention Regular sessions
Current setting
Priority setting
Parents key role player
Intensive block therapy
Timing is key
Behavioural factors
Personality and motivation
Mastering of current skills
Improved weight shifts transitions
Endurance
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Theories in Neurodevelopment
Neural Maturation Theories
Developed in the 1930’s and 1940’s
As the brain and musculo-skeletal system matures
Identified that development would follow:
Set sequence
Specific timing
Genetically determined
Developmental milestones
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Theories in Neurodevelopment
Neural Maturation Theories (cont)
General concepts
Cephalo-caudad
Proximal-distal
No interaction from environment
Development is the gradual cortical control over lower reflexes
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Theories in Neurodevelopment
Dynamic Systems Theory
Interest in development was rekindled in the 1980’s
How does the external, peripheral and perceptual factors influence development
Factors all need to be in place for learning to take place
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Theories in Neurodevelopment
Perception-Action Approach
Perception and movements strongly linked
Perception required for adaptive movements
Perception of environment, body,
Perceptual information requires movement
Exploratory movements of eyes/limbs/head/body
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Theories in Neurodevelopment
Neuronal Group Selection Theory
No specific cortical pathways but
Variation is present in
Sequence
Duration
Dynamic ensemble of cortical and subcortical systems arranged in networks of interconnected neurons- neuronal groups
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Theories in Neurodevelopment
NGST states that “development starts with primary neuronal repertoires”
Each repertoire consists of multiple neuronal groups
Variation decreases as behavioural and experience changes
Secondary repertoires develop
Situation specific
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NTSG
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Theories in Neurodevelopment
NEURAL MATURATION
PERCEPTION – ACTION THEORY
DYNAMIC SYSTEMS THEORY
NEURONAL GROUP SELECTION THEORY
• Provides basis for milestones
• Understanding of why primitive reflexes disappear
• Provides link between nervous system and environment
Equal link between nervous system and external factors
• Situation based • Task specific • Variable
sequence • Variable period
NATURE NURTURE
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How do these theories relate to early assessment?
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Morrow (Startle) Reflex
When baby hears a loud noise, will thrust arms out and head back and start crying
Integrated at +- 6months
If persists
interferes with sitting and other postures
Inability to develop equilibrium and protective reactions
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Asymmetrical Tonic Neck Reflex
When head turned to the side the ipsilateral arm extends
If persistant
Struggles with bilateral integration
Midline activities
Later skills like crawling, dressing, hand writing may also be poor
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Rooting reflex
Helps the baby find the nipple when side of cheek is stroked
Integrated by 3-4 months
If prolonged can result in asymmetry.
Struggle with midline
Fix and follow
prone lying
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Grasp Reflex
Baby closes fingers tightly when palm stimulated
Fades in a few months
If weak: poor hand development
Exploration of objects and environment
if too strong Difficulty to release
objects
In-hand manipulation
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Step Reflex
When supported under the arms and feet touch the floor, baby will take steps
If persists
Over active extensors
Muscle imbalance
Poor flexor and midline development
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As an aside
Poor bilateral integration
Poor trunk control
Muscle imbalance
Visual-perceptual problems
Spatial awareness
Scapular control
Fine motor problems
Muscle contractures
Injuries
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Assessment Tools
Infant Neuro-motor Assessment
Touwen Infant neuro-motor Assessment
Alberta Infant Motor Scales
Assesses “traditional” neurological signs
Tone
Reflexes
Assesses posture, symmetry, function in various positions
Quick easily reproducible tests
Ideal age for assessment is 18 weeks corrected age
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Prechtl General Movement Assessment
General Movements
Are spontaneous movements present from early foetal life till the 1st half of life
Thought to be produced by Central Pattern Generators (CPG)
Complex movements and involve the whole body
Variable sequence of movement between arm, neck, leg and trunk
Amplitude
Velocity
Intensity
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Prechtl General Movement Assessment
Changes in:
Velocity
Force
Speed
Intensity
Gradual beginning and end
Fluent and elegant
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Prechtl General Movement Assessment
Are assessed on the awake alert baby
Must not be irritable or fussed, tired
A 30 - 60 minute video recording in the preterm infant
5-10 minutes needed for term infant
Minimal disturbances and distractions during recording
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Prechtl General Movement Assessment
Writhing Movements
Age:
term 2months
Characterised by:
Small to moderate amplitude
Slow to moderate speed
Elliptical “writhing” movements
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Prechtl General Movement Assessment
Fidgety Movements
Age:
69 weeks
As writhing movements disappear
Characterised by:
Small amplitude
Moderate speed
Variable acceleration
Of neck, trunk and limbs
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Prechtl General Movement Assessment
Fidgety Movements
May be associated with other movements
Fiddling
Wiggling
Swiping
Finger and hand manipulation
Reaching and touching
Axial rolling
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Prechtl General Movement Assessment
Abnormal General Movements
Hypoxic-Ischaemic lesions
Leukomalacia
Haemorrhage in the Corona Radiata
Peri-Ventricular lesions
Quantity vs. quality
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Abnormal General Movements
Cramped Synchronised
“rigid” lacking smooth fluid movements
Poor dissociation
High predictive value for spastic CP
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Abnormal General Movements
Poor Repertoire
Monotonous sequence of movements
Lacks the complexity
Often found in infants with abnormal brain US
Low predictive value for CP but may indicate Minor Neurological Dysfunction
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Abnormal General Movements
Abnormal or Absent Fidgety
May look like normal GM
But amplitude, speed, jerkiness are greatly exaggerated
Absence is highly predictive of later neurological dysfunction, particularly CP
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Abnormal General Movements
Chaotic GM
Large amplitude
No fluency or smoothness
Abrupt
Often develop into Cramped Synchronised GM
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Interpreting GMs
Signs of CP
Cramped GM predictor of Spastic Quadriplegia and Diplegia
Hemiplegia
Bilateral Cramped GM with subsequent Absent Fidgety movements or poor repertoire
Asymmetry in segmental movements: reduced or absent on contralateral side of lesion
May be evident during 2nd month
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Interpreting GM
Dyskinetic CP
Poor repertoire
Arm movement in circles with finger spreading
May be present up to 5 months post term
Unilateral or bilateral
Monotonous
Lack of movements to midline
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Minor Neurological Dysfunction
Simple MND
Motor dysfunction with a normal but NON optimal brain function
May progress well through developmental milestones but struggle fine tuning task specific activities
Clumsiness
DCD
Complex MND
Pre & perinatal brain dysfunction
“borderline” CP
Associated more with dystonia and hypotonia
Reflexes may vary
Clumsy motor behaviour
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Cluster of Dysfunction
Sign Criteria for dysfunctional cluster
MND Complex MND
Dysfunctional Muscle tone
• Abn tone • Abn posture
during sitting, walking, crawling, standing
Consistent mild deviation in one
1 cluster dysfunction
2 or more clusters dysfunction
Abnormal reflexes Abn intensity or asymmetry in tendon reflexes
Presence of 2
Gross motor dysfunction
Discoordination during crawling, block movements of trunk, age inadequate imbalance, maneuverability
Presence of 2
Fine Motor dysfunction
Hand preference, poor quality arm and hand movements
Presence of 2
Rarely occurring disorders
Motor behavior of face, eyes, tongue, tremors
Presence of cranial nerve palsy or consistent tremor
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Minor Neurological Dysfunction
Often neglected or not identified until much later
Most often identified in the school going age when specific tasks are required.
Problems with
bilateral integration
Gross motor impairment
DCD or clumsiness
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conclusion
Early assessment is vital
Use combination of traditional screening tools as well as others such as the GM assessments
Early intervention can be started as soon as possible with individualized treatment programs
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Thank you
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References
Hadders-Algra; Developemtal coordination disorder: Is Clumsy Motor behavior caused by a Lesion in the Brain at Early Age?;Volume 10, no.1-2,2003 Neural Plasticity
Blauw-Hospers; A systematic Review of the Effects of Early Intervention on Motor Development; Developmental Medicine & Child Neurology 2005;47: 421-432
Prechtl H; An Early marker for Neurological Deficit after Perinatal Brain Lesions; The Lancet; Vol 349, May 1997
Hadders-Algra; The Assessment of Minor neurological Dysfunction in Infancy using Touwen Neurological Examinations: Strengths and Limitations; Dev Medicine & Child Neurology,2009
Adolph K; Motor Development; galley Article- 00584
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References
Einspeler C; Prechtl’s Assessment of General Movements: A Diagnostic Tool for the Functional Assessment of the Young Nervous System; Mental Retardation and Developmental Disabilities;2005; 11:61-67
Sauve K; Dynamic Systems Theory: a Framework for Exploring readiness to change in Children with cerebral Palsy; 2010; CanChild for Childhood Disability Research
Hadders-Algra; The Neuronal Group Selection Theory: Promising Principles for Understanding and Treating Developmental Motor Disorders; Dev medicine and Child Neurology,2000, 42: 707-715
Heineman K; The Infant Profile: a Standardized and Qualitative method to Assess motor behaviour; Dev medicine & Child Neurology 2008, 50: 275-282
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