Role of the neonatal physical therapist

The role of the physical therapist (PT) in a neonatal intensive care unit (NICU), transitional care unit, or follow-up clinic is to evaluate and treat the sensorimotor function of the developing infant. Physical therapists trained to work in this clinical area are not only considered specialists in the multifaceted aspects of infant development, but are also acute care specialists, with extensive clinical expertise in dealing with critically ill pediatric patients. The purpose of an evaluation by a neonatal PT is to

• 
  

  Recognize musculoskeletal impairments.

  
  
• 
  

  Identify positioning techniques to improve flexion.

  
  
• 
  

  Determine ways to enhance neurobehavioral organization through adaptations in the infant’s environment.

  
  

  The physical therapist’s goal of promoting an infant’s sensorimotor development needs to be addressed as soon as the parent and the infant are stable after birth. Providing positioning and environmental recommendations to the parents and nursing team can be instrumental in preventing posture and movement deviations typically seen in acutely ill infants. A PT is often one of the first team members to educate parents on the specific developmental needs of the “high-risk infant.”

Patient population

The typical patient population seen by the neonatal PT can be divided in two main categories: preterm and sick term infants. These patients are often termed high-risk infants because, although their early life experiences are very different, they show similar posture and movement deviations that can lead to delays in gross motor development. These deviations include

• 
  

  An overall extension bias in both posture and movement (Figure 44-1)

  
  
• 
  

  Lack of varied and vigorous spontaneous movement, especially flexion against gravity

  
  

  These tendencies are the result of the infant’s medical diagnoses, as well as a result of prolonged illness/immobility in the NICU.

Normal developmental sequence of gross motor skills

The fetal environment can strongly influence physiologic development throughout infancy and early childhood. The following is a general guideline for motor milestones typically achieved in the first 6 years of life. Variability within the provided ranges can be expected.

0 to 2 Months

• 
  

  Kicks legs alternately while in supine

  
  
• 
  

  Bends and straightens arms

  
  
• 
  

  From right or left side, rolls to supine

  
  
• 
  

  Turns head cheek to cheek in prone

  
  
• 
  

  May lift head to ~45? in prone

  
  
• 
  

  Bears weight through flat feet in supported standing with knees bent

  
  
• 
  

  Holds head upright in supported sitting for several seconds

3 to 4 Months

• 
  

  Holds head in midline and brings hands to midline/mouth while in supine

  
  
• 
  

  Smooth (alternating or together) movements in arms and legs

  
  
• 
  

  Grabs knees by flexing trunk

  
  
• 
  

  Lifts head/trunk 45? to 90? off the surface in prone with weight on forearms

  
  
• 
  

  Rolls from prone to supine and may be able to roll supine to prone

  
  
• 
  

  Holds head steady in supported sitting position

5 to 6 Months

• 
  

  Plays with feet while in supine

  
  
• 
  

  Rolls over in both directions (prone to supine and supine to prone)

  
  
• 
  

  Pushes chest off surface and arms straight while in prone

  
  
• 
  

  Begins to sit without support (may use arms on support surface)

  
  
• 
  

  Bears full weight through legs and may bounce

7 to 8 Months

• 
  

  Shifts weight on arms to reach for toy while in prone

  
  
• 
  

  Sits unsupported with hands free to play with toys

  
  
• 
  

  Consistently rolls in both directions

  
  
• 
  

  Begins to commando crawl (uses arms to move forward while on stomach)

9 to 11 Months

• 
  

  Rocks in quadruped

  
  
• 
  

  Creeps on hands and knees with arms and legs alternating movements

  
  
• 
  

  Sits steadily and can pivot around in sitting to play with toys

  
  
• 
  

  Catches self with arms when loses balance in sitting

  
  
• 
  

  Pulls to stand on steady object

  
  
• 
  

  From standing, lowers to seated position uncontrolled

  
  
• 
  

  Can get into sitting position unassisted

12 to 14 Months

• 
  

  Pulls to stand and cruises (holding onto furniture)

  
  
• 
  

  From standing, lowers to seated position with graded control

  
  
• 
  

  Begins to stand alone

  
  
• 
  

  Begins walking alternating feet, holding onto adults hand

  
  
• 
  

  Creeps up steps on hands and knees

  
  
• 
  

  Begins to kneel

15 to 18 Months

• 
  

  Stands alone well

  
  
• 
  

  Squats to pick up toy and returns to standing

  
  
• 
  

  Walks forward well

  
  
• 
  

  Begins to walk backward (may pull toy)

  
  
• 
  

  Creeps backwards down steps unsupported

  
  
• 
  

  Begins to walk up steps using “step-to” pattern with support

  
  
• 
  

  Lifts foot to imitate kicking ball

  
  
• 
  

  Throws 3-in ball

19 to 23 Months

• 
  

  Squats to play

  
  
• 
  

  Begins to run—unsteady

  
  
• 
  

  Jumps forward without falling

  
  
• 
  

  Kicks ball (with demonstration)

  
  
• 
  

  Throws ball underhand

2 Years

• 
  

  Stands on tiptoe

  
  
• 
  

  Kicks a ball (without demonstration)

  
  
• 
  

  Climbs onto and down from furniture without help

  
  
• 
  

  Walks up and down stairs using “step-to” pattern with handrail

  
  
• 
  

  Throws ball overhand

3 Years

• 
  

  Climbs well

  
  
• 
  

  Runs easily

  
  
• 
  

  Pedals a tricycle (three-wheel bike)

  
  
• 
  

  Walks up and down stairs, alternating feet

4 Years

• 
  

  Hops and stands on one foot up to 2 seconds

  
  
• 
  

  Catches a ball most of the time

  
  
• 
  

  Runs and stops without losing balance

  
  
• 
  

  Walks on a balance beam

5 to 6 Years

• 
  

  Stands on one foot for 10 seconds or longer

  
  
• 
  

  Hops or skips

  
  
• 
  

  Descends stairs without railing

  
  
• 
  

  Can do a somersault

  
  
• 
  

  Swings and climbs

Transition from the uterine environment to the intensive care setting

The birthing process is a significant transition between two entirely different worlds, especially if the infant requires intensive medical care. The marked difference between the uterine environment and the NICU is especially important in the preterm infant as the baby is not prepared physiologically, or neurodevelopmentally, for the experiences the NICU environment provides.

Based on the theory of neuronal group selection, the brain’s organizational development is influenced by both the body’s physiologic systems and the environments before and after birth.

1. 
   

   In utero, the fetus experiences

   
   
   
   
   1. 
      

      Slow, graded proprioceptive input from the mother’s movement that aids in development of kinesthetic awareness

      
      
   2. 
      

      Muffled sounds via vibrations in amniotic fluid

      
      
   3. 
      

      Diurnal rhythmicity

   
   
2. 
   

   In contrast, a preterm infant in the NICU experiences

   
   
   
   
   1. 
      

      Touch with less consistency

      
      
   2. 
      

      Few opportunities for graded proprioceptive input

      
      
   3. 
      

      Abrupt positional changes

      
      
   4. 
      

      Harsh sounds and lights due to less filtration

      
      
   5. 
      

      Lack of day to night cycles

Behavioral and motor reactivity in the preterm infant

As a result of the marked differences between the uterus and NICU environment, the preterm infant is easily overwhelmed and responds with behaviors and specific movement patterns, often called stress signs, which are listed below.

• 
  

  Pallor, cyanosis, mottling, or flushing

  
  
• 
  

  Autonomic nervous system instability

  
  
• 
  

  Gagging, hiccups, sneezing, yawning

  
  
• 
  

  Significant hypotonia of extremities

  
  
• 
  

  Finger or toe splaying (Figure 44-2)

• 
  

  Frantic flailing movements (Figure 44-3)

  
  
• 
  

  Excessive extension patterns

  
  
• 
  

  Poor sleep states with twitching or grimacing

  
  
• 
  

  Gaze aversion

  
  
• 
  

  Staring with locked gaze, usually wide open eyes

  
  
• 
  

  Panicked look/furrowed brow

In order to minimize these stress signs, the preterm infant requires individualized medical and nursing care that adapts to the infant’s specific needs with a developmentally supportive environment and handling.

Common postural and movement deviations in the high-risk infant

1. 
   

   The uterus provides the optimal environment for neuromuscular maturation and motor skill acquisition for the fetus by maintaining constant containment throughout the fetus’ flexed body. The uterine wall continually guides the active fetus back to midline positioning, resulting in strong physiologic flexion and midline orientation in the term infant (Figure 44-4A).

   
   
2. 
   

   When birth occurs prematurely, muscle tone, posture, and movement continue to develop, but the infant now must adapt to the influence of gravity and tactile and proprioceptive stimuli from prolonged lying (weight-bearing) on a mattress before the musculoskeletal system is equipped to deal with these forces (Figure 44-4B).

   
   
3. 
   

   The preterm infant’s movement is

   
   
   
   
   1. 
      

      Gravity dependent, resulting in development of strong extension movement patterns of the trunk and extremities and central hypotonia (Figure 44-5).

      
      
   2. 
      

      Imbalanced, between active extensors and less active flexors that is reinforced neurologically through a lack of supportive positioning.

   
   
4. 
   

   Posture and movement deviations in the preterm infant

   
   
   
   
   1. 
      

      Lack of physiologic flexion and contractures at hips, knees, and elbows as a result of no uterine crowding (Figure 44-1), leading to poor head control and midline orientation

      
      
   2. 
      

      Extension bias related to stress, reflux, or gravity-dependent positioning of the infant (Figure 44-6)

      
      
   3. 
      

      Posture and movement with imbalance between flexor and extensor muscle groups

      
      
   4. 
      

      Hypotonia, especially centrally (Figure 44-7)

      
      
   5. 
      

      Foot/ankle eversion—outwardly turned feet secondary to muscle imbalance or medical devices (pulse oximeters, intravenous lines, etc) (Figure 44-8)

      
      
   6. 
      

      Difficulty with self-regulation—poor self-calming and reorganizational skills

      
      
   7. 
      

      Difficulty with smooth transitions between states of awareness (sleep, drowsy, quiet alert, active alert, and crying)

      
      
   8. 
      

      Poor cranial molding

      
      
      
      
      • 
        

        Scaphocephaly: Flattening on bilateral surfaces of skull resulting in a long “boat-shaped” head. Scaphocephaly is a result of frequent positioning in side lying or prone as well as the infant’s inability to maintain midline positioning of the head while supine (Figure 44-9).

        
        
      • 
        

        Plagiocephaly: Posterolateral flattening of skull also seen in premature infants as the result of a cervical rotation preference. Care is typically provided from the infant’s right side in the NICU, which can cause infants to develop a right-sided head preference. Discomfort from reflux symptoms can also cause asymmetrical movement tendencies leading to a right cervical rotation preference.

   
   
5. 
   

   The sick term infant experiences similar effects of gravity- dependent positioning and movement from prolonged hospitalization, sedation, and/or mechanical ventilation. Self-initiated movement is often limited due to sedation, discomfort from respiratory support, or other medical support devices and leads to poor endurance and muscle coordination. In addition, the onset of primitive reflexes often reduces midline positioning, causing asymmetrical cranial molding and musculoskeletal alignment.

   
   
   
   
   1. 
      

      Sick term infants should be swaddled and/or supported in flexed positions to prevent the onset of extension movement patterns, excessive hip abduction and external rotation (“frogged legs”), and foot eversion from pull of intravenous lines or pulse oximeters (Figure 44-6).

   
   
6. 
   

   Posture and movement deviations in the sick term infant

   
   
   
   
   1. 
      

      Shortened hip abductor muscles and iliotibial (IT) bands (ie, frogged leg position), neck hyperextension, and shoulder retraction (Figures 44-10 to 44-12).

      
      
   2. 
      

      Prolonged time spent in supine position leading to increased activation of posterior muscle groups (neck, trunk, and hip extensors) (Figure 44-13)

      
      
   3. 
      

      Poor cranial molding

      
      
      
      
      • 
        

        Brachycephaly: Posterior flattening of the skull commonly seen in sick term infants with prolonged supine positioning.

        
        
      • 
        

        Plagiocephaly: Posterolateral flattening of the skull also seen in sick term infants as a result of a preference for cervical rotation.