Reversing Cerebral Palsy in Early Infancy (eBook)

THREE MONTHS CHRONOLOGICAL OR ADJUSTED AGE

At three months of age, the infant with Cerebral Palsy will demonstrate indications of using excessive extension patterns and lack of a variety of general movements. He will arch back when lying on his back, with his face turned to one side and his cervical spine, thoracic spine and lumbar spine in strong extension, with shoulders in strong retraction. He is likely to arch back when he is held. In supine, he may extend and retract his shoulders so that he cannot bring his hands to midline. His hands may be tightly fisted and his feet may be pointed down in plantar flexion. NTNM protocol can be implemented to prevent abnormal movement patterns from strengthening. Usually after a week or two of preventing extension and promoting normal movements that balance flexion with extension, the abnormal extension is corrected enough so that normal movement is available when the infant is placed in a rounded position. However, excessive extension may still be present in other positions. Stopping abnormal movements that use excessive extension is achieved by positioning and then interacting with the infant while keeping him in a flexed position.

This rounded position can be very difficult to accomplish in prone and in supine, either with positioning or with handling, because the infant has strong habits of extending in prone and in supine. A seated position in an infant seat or on the parent’s lap with his back against the parent works well to get rounding at three months of age. After the infant is in rounded position, interactions with him should be done with the parent approaching him from his feet. The infant should be looking down for the interactions, encouraging cervical flexion with chin tuck. When held in the parent’s arms during feeding, keep the rounded position and feed him in a position that does not include cervical extension, instead, keeping his head in a neutral position. The rounded position should allow the infant to bring his hands to midline. While in a rounded position, encourage him to feel toys and textures by placing them at midline and letting him explore them with his hands. We can teach him to reach his hands to his face and suck his thumb. Oblique abdominal muscles can be stimulated to contract by bring our hands gently down on his rib cage from clavicles toward his navel.

Signs of Excessive Extension at Three Months.

If an infant has any of the characteristics listed below, he may be showing signs of Cerebral Palsy and should be evaluated by a physician or physical therapist. A reliable and valid assessment for infants from 9 weeks post menstrual to the end of the 5th month post term is The General Movement Assessment (GMA)5 which was discussed in the section of this book titled The General Movement Assessment (GMA).

Here are some early symptoms to look for in an infant with possible developmental concerns: These symptoms were described by Pathways, a pediatric therapy center in Glenview, Illinois.6

• Poor head control after 3 months
• Stiff or rigid arms or legs
• Pushing away or arching back
• Floppy or limp body posture
• Cannot sit up without support by 8 months
• Uses only one side of the body, or only the arms, to crawl
• Extreme irritability or crying
• Failure to smile by 3 months
• Feeding difficulties
• Persistent gagging or choking when fed
• Tongue pushes soft food out of the mouth after 6 months

I have added some personal observations to the Pathway’s list. They pertain especially to infants at risk for Cerebral Palsy and are:

• Infant seems to be tense and tight throughout his body.
• Hands that stay fisted and/or feet that stay pointed.
• Infant uses one arm freely, but not the other.
• Infant keeps his head back in strong cervical extension.
• Infant keeps shoulders back, pulling back at the scapulae.
• Infant arches whole spine and body into a curve to one side when lying on his back.
• Infant does not have a variety of movements. For example, does not kick with both legs and move hands and arms in random movements, turning head from side to side.
• When lying on his tummy, infant arches back, taking weight on his abdomen with his shoulders retracted at the scapulae.
• Infant arches back when held instead of leaning into you.
• If placed in sit, the infant arches back out of the sitting position, pushing against your hands to get back to lying in extension.

Excessive Extension of Cerebral Palsy

Prone with excessive extension of Cerebral Palsy. Cervical, thoracic and lumbar extension with arms and legs straight and stiff and toes pointed.

Positioning to Correct Excessive Extension.

When the infant is placed in prone or supine, he will use the extensor patterns that his nervous system is programmed to use and that are habitual for him. We need to position the infant so that we can change the nervous system function out of excessive extension and into a rounded position that allows the infant to use flexion to balance the extension.

Stopping abnormal movements that use excessive extension is achieved by keeping the infant in a rounded position where he can relax and stop extending. We do this by rounding the entire cervical, thoracic, and lumbar spine:

• Position the infant in an infant seat where he relaxes without extension,
• Use a carrier sling which keeps him in a rounded position. The sling needs to be checked carefully to make sure that the entire infant is rounded. Some carriers allow for cervical spine extension and shoulder retraction. The sling should keep the entire infant in a rounded position.
• Have him sit on his parent’s lap with his back against his parent
• Have the parent hold him in a position that prevents extension.
• Remember a rounded position includes keeping head and neck in flexion, shoulders forward out of retraction and keeping knees and hips flexed.

Description of the flexed and rounded position.

The flexed position includes keeping his head with the cervical spine in a flexed position with the head in neutral, chin toward the chest and not up in cervical extension. The infant’s shoulders are forward with the scapulae forward and not pulled back into retraction. Hands should easily meet at midline. Keep hips and knees and lumbar spine flexed, with the pelvis rounded.

Side view of parent’s hand position when holding infant in parent’s lap in rounded position with no extension. Support at scapulae and ribs. Infant has trunk flexed forward, away from parent’s chest.

Age appropriate movements for an infant three months old.9

Prone position

• At three months of age, the infant who does not have Cerebral Palsy should be using prone on elbows position with his elbows directly under his shoulders and his head up to 90 degrees with face forward in a chin tuck
• Prone on elbows position as described above strengthens shoulder flexors and brings the shoulders out of retraction. It strengthens muscles needed for head control.

Supine position

• In supine position, the three-month-old infant brings his hands forward to midline and moves his arms and legs freely in varying positions. He keeps his head in midline much of the time

Sitting position

• In sitting position, the three-month-old without Cerebral Palsy sits with support at his ribs with his spine rounded. He may use shoulder elevation to help support his head, appearing to not have much neck.

Standing position.

• In supported stand, the infant takes weight on his feet with his trunk flexed.

Active movements for the infant who uses excessive extension which encourage the balance of flexion with extension needed for age appropriate movement.

Prone position. Active movements for the three-month-infant with Cerebral Palsy

• The infant with Cerebral Palsy uses very strong extension when placed in prone with his shoulders retracted, head in cervical extension, often taking weight on his abdomen and not on his arms. He does not use prone on elbows position.
• We can get weight on elbows by placing him upright on his parent’s shoulder with hips and knees flexed and by having a second person place his elbows under his shoulders with his head in neutral and looking straight ahead or down. If he extends when we do this, take him back into a rounded, relaxed position in sit until he is ready to assume the above position of weight bearing on elbows with hips and knees flexed.
• Some shoulder muscles extend up through the neck to the head. Strengthening shoulders in prone position also strengthens head control. Gently help him to get his elbows under his shoulders when he is held upright on or near his parent’s shoulder.

Supine position. -Active movements for the three-month-old infant with Cerebral...