Prof. V Wong

2.5/F hypotonia (floppiness)

Posture:

• Supine - Chinese char for 'big' = 'dai' - frog posture, widely abducted hips, knees flat on floor. Look at different postures; pull up, roll back and forth, vertical / lateral suspension, pulling up no flexion of arms, sitting in C-shape
• Lateral suspension: inverted U-shape
• Vertical suspension: slipping through shoulder sign
• Scarf's: lying on back, shoulders on floor, elbow should not pass midline

Weakness:

• No weakness - spontaneous movt of limbs
• Pt rolling over from supine to half-prone position
• Moving limbs actively (knees, hips)
• Therefore floppiness due to central region, not LMN region

2.5yr

• Therefore sit up with good head control

Limbs very hypotonic, jt laxity

• Heel ear test, more than 180 degrees
• Scarf's sign: can wrap neck with arm
• Hyperlaxity of ankle, knee, hip (widely abducted)
• Shake limbs - excessive tone

Jerks

• When knee relaxed, flex knee and tap tendon
• Can see jerks
• Cross-adductor reflex - usually not present after 18mo
• Ankle, Tricep, Supinator, Bicep
• All jerks present - grades: normal, hyperactive, increased
• Babinski: scratch lateral side of sole; UMN sign is fanning of toes and extension of big toe
• Don't do in centre - plantar reflex (normal in all infants over age 9mo)

Besides floppiness, a lot of involuntary movt of UL

No response to name

Pull to sitting - lack of head control

Can child sit? Lots of wriggling movt

Vertical suspension - hold under armpits- - slipping through shoulders

Ventral suspension: 4 limbs dangling down in floppy baby

Prone posture (lying on front)

• Should be able to lift head and support on UL
• No support around pelvis

Cannot bear weight and walk

Cause: severe neural delay

4/M

One of triplet, premie

Delayed gross motor development

Posture of spastic

UL

• Shoulder adducted
• Elbow flexed
• Wrist pronated
• Fingers flexed
• Adducted thumb (cortical thumb)
• Fisting of hands

LL

• Scissoring
• Adductors tight: adductor magnus, brevis
• Spasticity adductor: flex knees, and abduct hips, see tightness around adductors
• Spasticity of ankles; dorsiflex ankles, when knees ankles and then flexed due to different attachments of gastrocnemius and soleus
• Walking: marked scissoring of lower limb, increased tone of LL (spasticity)
• Tip-toeing: spasticity in calf muscles (gastrocnemius and soleus) - walk with plantar flexed feet
• Adductors are spastic therefore scissored walking
• Cerebral palsy with spastic diplegia

Ask where is mother? Baby points at mother

• When excited, upper limbs have fisting posture
• Ask baby to release hands
• Spasticity of hand function
• Lower limb tone - markedly hypertonic

LL

• Posture
• Plantar flexed posture
• Spasticity affects flexural muscles
• Demonstrate spasticity - move limbs quickly
• Clasp-knife spasticity
• Adductor spasticity: quick abduction with knees flexed
• Knees extended: dorsiflex at ankle to test for gastrocnemius and soleus spasticity
• Flexed knee - better response, releases gastrocnemius (tendon attached above knee) - therefore only tests soleus (tendon attaches below knee)
• Spasticity of both LL

Jerks

• Knee jerk - brisk (UMN sign)
• Ankle jerk - brisk
• Brisk - jerk can be elicited with finger tap; tap afferent areas like thigh also elicits response

Ankle clonus

• Support knee, sustained plantar flexion of foot, clonus

 Babinski

• Get child's permission / inform
• Babinski positive - toe extension and toe fanning

Fisted posture

• Normally baby will open up fingers

UL

• Pt to look at examiner
• Clasp-knife on left arm
• Difficult to touch thumb and index finger

Pull to sitting posture

Increased tone in lower extremities

Standing: Pt with increased tone can stand before he is able to sit

Can sit balanced due to hamstring tightness, therefore hands out to side

Pull to standing: legs are straight

Parachute: protective secondary reflexes

ATNR: primitive reflex (Asymmetric Tonic Neck Reflex)

All normal babies from 6w to 6m

If persists, abnormal

Tx

• Physio
• Injections - increase tone in calf muscles to get rid of tip-toeing walking

1. Gross motor
2. Fine
3. Social
4. Vision
5. Hearing
6. Language

Need assessment for hearing and vision because child won't c/o any deficits in these areas

KNOW MILESTONES! Multiples of 3

• 3m head
• 6m sitting
• 9m standing
• 12m walking
• First words 'mama'
• 6m turn to sound