evaluare copii

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27Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 2

Importana evalurII precoce senzItIvo-motorII a nounscutuluI cu rIsc de ctre kInetoterapeut

Importance o precocIous sensory motor assessmentby the kInesIotherapIst o the rIsk new-born baby

r lii1, bj cii2, c mi3, c e4

rezumat

Scderea mortalitii perinatale nu a ost urmat de o scdere concomitent a morbiditii, ci a survenit chiar o cretere aprevalenelor defcienelor motorii i senzitive. Graie progresului tehnic privind ngrijirea perinatal a copiilor prematuri sau cugreutate oarte mic la natere, acetia supravieuiesc, dar apar cazuri mai multe cu defcit neurosenzorial.n orice caz, indierent de vrsta gestaional i de greutate, orice nou nscut cu o patologie sever sau moderat, necesit o su-praveghere atent de ctre neonatolog, realizndu-se bilanuri neuromotorii la natere i apoi la intervale regulate, iar bilanulkinetoterapeutului se poate ace ncepnd cu vrsta corectat de 34 sptmni.Aceasta evaluare nu se substitue examenului medical (clinic, imagistic, EEG, poteniale evocate vizuale i auditive etc,), ci con-stitue un complement indispensabil n supravegherea periodic a nou nscutului.Se urmrete o stimulare precoce a copilului, destinat s reduc eventualul handicap, concomitent cu instruirea prinilor pentru

poziionarea i mobilizarea nou-nscutului.Cuvinte cheie: nou nscut cu risc, prematuritate, kinetoterapeut, evaluare precoce.

abstract

Reduction o perinatal mortality has not been ollowed by a concomitant reduction o morbidity ; on the contrary, there is a rise inthe prevalence o motor and sensory defciencies. Tanks to the technological progress in perinatal care o the premature inantsor o those with a very low weight at birth, they survive indeed but there are a lot o cases with neurosensory defcit.Anyway, in spite o its gestational age and o its weight, any new-born inant with severe or moderate pathology, requires atten-tive supervision by the neonatologist so that neuromotor assessments are perormed frst at birth, then at regular intervals, andthe kinesiotherapist assessment may be perormed starting with the corrected age o 34 weeks.

Tis assessment should not replace the medical examination (clinical, imagery, EEG, visual and auditory evoked potentials, etc.);on the contrary, they constitute an indispensable complement in the periodical supervision o the inant. Te aim is to stimulatethe inant early so as to reduce the possible handicap concomitant with the training o the parents or the positioning and themobilization o the new-born inant.Key words: new-born inant at risk, prematurity, kinesiotherapist, early assessment

referat general

1 MD, medical rehabilitation, Bucharest2, 3, 4 Kinetotherapist, Bucharest

Correspondence address:Hospital Pro. Dr. Al. Obregia BucharestClinic o Paediatric NeurologyBerceni street, Sector 4 Bucharest

1 Medic specialist recuperare medical, Bucureti2, 3, 4 Kinetoterapeut, Bucureti

Adres coresponden:Spitalul Clinic de Psihiatrie Pro. Dr. Alexandru Obregia - BucuretiClinica de Neuropediatrieos. Berceni, Sector 4 Bucureti


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28 Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 2

Este cunoscut aptul c scderea mortalitii in-antile nu a ost urmat de scderea concomitent amorbiditii, ci a survenit chiar o cretere a prevaleneidecienelor neurosenzoriale.

Graie progreselor tehnice privind ngrijirea copii-

lor prematuri sau cu o greutate oarte mic la natere,acetia supravieuiesc, dar apar cazuri mai multe cudeciente neurosenzoriale.p fi (lq, v)

nscui la termen cu greutate > 2500 g. 1/1000nscui ntre 32-36 sptmni, greutate 1500-2500g. 1%nscui sub 32 sptmni, greutate < 1500g 6%

Grupul de Supraveghere European al Paralizieicerebrale conchide c: la vrsta de 5 ani:

31% din cazurile de mai sus nu merg indepen-dent

16% se deplaseaz cu ajutor 53% merg independent

i i iii i fi i i:

Prematuritatea < 32 sptmni de gestaie Greutatea la natere < 1500g. ntrzierea n creterea intrauterin Hipertensiunea gestaional

Inecii pre sau perinatale Nateri multiple, dup care poate apare pre-

maturitatea Asxia perinatal Incompatibilitatea Rh Prevalena sexului masculin la prematuri.

Indierent de vrsta gestaional i greutate, oricenou nscut (nn) cu o patologie moderat sau sever,

va atent supraveghiat dpdv: neurosenzorial, psihomotor

cretere, patologie respiratorie i digestiv psihologic - comportamental-somn socioamilial limbaj-comunicare.

Examinarea copilului de ctre medic (Bournier): 0 - 1an: la natere, la 40 sptmni de gestaie,

la 3 luni, la 4 luni, 6 luni, 9 luni vrsta corectat (VC) 1 - 2 ani: 12 luni, 18 luni, 24 luni VC 3 - 6 ani: anual.

Bilanul kinetoterapeutului se poate realiza nce-

pnd cu 34 sptmni VC.n orice caz, dupa externarea din maternitate, esteoarte important ca medicul de amilie s preia ur-

mrirea copilului, urmnd s ndrume amilia ctreneurolog i ctre centrele specializate n tratamentulde reabilitare.ex ii i

Dezvoltarea neuromotorie este rezultatul inuen-

ei combinate a actorilor genetici i de mediu, caredesavresc schemele cele mai eciente de micare.Aptitudinile motrice ale n.n. la termen sunt carac-

terizate prin: hipotonie axial hipertonie membre reexe arhaice activitate motric spontan complex i

variabil.n :

n ultimul trimestru de gestaie, etusul poziionatcu spatele la peretele uterin, are tendina la exie.Prematurul, care nu traverseaz aceast perioad

intrauterin, este hipoton, nu se poate regrupa spon-tan. (Bullinger, Ros)

Absena posibilitii de regrupare are consecine: avorizeaz o postur asimetric, mpiedic

rotaia bustului i deasemeni mpiedic sugarul s-ipriveasc minile. (Ferraud)

este necesar poziionarea copilului n exie(poziie etal) pentru a iniia o relaie vizual, auditiv

i pentru a obine calmarea sugarului. predomin schema n extensie, ca i poziia

asimetric, perturbnd achiziiile neuromotorii, maiales evoluia spre simetrie.

schema corporal evolueaz n triada: plagio-cealie, als torticolis, hemisindrom, situaie agravatn cazul leziunilor neurologice.

muli prematuri se menin n poziia de ba-

tracian datorita hipotoniei musculare i insucieneimicrilor spontane. (Fig. 1 - Postura batracian)

Fig. 1 - Postura batracian (dup Amiel-isson)


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n aceasta situaie, psoas iliacul i adductorul mij-lociu sunt scurtai, avoriznd o rotaie intern a dia-zelor emurale i posibilitatea de luxaie anterioar acapului emural.

Sarcina neonatologului este de a asigura din prima

zi o postur ziologic, cu coapsele n uoar abducie,genunchii n semiexie, deasupra planului patului.

(Fig. 2 - Posturarea corecta a prematurului)fi. 2 - Posturarea corect a prematurului (Amiel-isson)

activitatea motric insucient xeaz muchiin poziii scurtate, astel acetia i pierd extensibilitatea.

de exemplu, poziia n candelabru a mem-brelor superioare datorit scurtrii trapezului superior,sau orecarea membrelor in. prin hipertonia adduc-torilor. (Fig. 3 - Postura n candelabru)

Deci prematurul are nevoie de regrupare n e-

xie pentru a-i exprima motilitatea cnd este corectpoziionat.n aara examenului eectuat de neonatolog, kine-

toterapeutul va ace un examen clinic al copilului, nmomentul cnd nu mai exist probleme cririce.

v f x: complementar celui medical.

Aceasta evaluare ar trebui eectuat n maternitatencepnd cu vrsta de 34 sptamni VC

Reexaminarea la 3 luni VC va conrma sauva inrma anomaliile de dezvoltare neuromotorii.

(Pinol, Ros) Reexaminri ulterioare periodice

Aceasta evaluare a kinetoterapeutului presupune: o legtura strns cu prinii copilului, instru-

indu-i pentru poziionarea i mobilizarea sugarului,pentru ameliorarea mobilitii i a alimentaiei i an-ume:

stimularea perioral care va ameliora dicul-tile de alimentaie, ca i uoar exie a ca-pului, ceea ce va avoriza distensia musculatu-rii paravertebrale cervicale i deci reexul dedeglutiie. (Grenier)

legnarea n poziie etal care va olositpn la 3 - 4 luni VC. (Fig. 4 - Legnarea n

poziie etal.)

Fig. 4 - Legnarea n poziie etal

poziionarea n postura Recamier permite

Fig. 3 - Postura n candelabru (dup Pinol B)


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starea de eliberare a sugarului prin susinereacapului. Astel, motricitatea i pierde caracterulreex, dispar micrile necontrolabile, copilul selinitete. (Grenier) (Fig. 5 - Postura recamier)

Fig. 5 - Postura recamier

instalarea n hamac crete calitatea somnului idiminueaz riscul deormaiilor, iar n timpulzilei este indicat poziionarea ntr-un coconconecionat din buret, pentru a asigura posturan exie. (Ferraud. Pinol)

atenie la poziionarea corect n timpul suptului postura ndelungat n DD poate avoriza

plagiocealia i alsul torticolis prin preerinacopilului de a-i menine capul nclinat pe oanumit parte, avoriznd o asimetrie tonichemicorporal. (Captier) (Falsul torticolis =pierderea extensibilitatii sterno-cleido-mas-toidianului)

postura asimetric a copilului poate avorizaatitudini scoliotice n C cnd poziionm su-garul n eznd.

oi ii i ii i (ai ti)Ce trebuie observat la un nou nscut ?1. O postur anormal : hiperextensie exagerata a capului si uneori a

trunchiului o nclinare a trunchiului (atitudine scoliotic n

C) predominena exiei active a capului.

2. Membre superioare:

atitudine n candelabru uni sau bilateral exie a pumnilor i adducia policelui3. Membre inerioare:

atitudine n extensie, rotaie intern, eventualorecare

dezechilibru al bazinului n plan rontal atitudine in echin a picioarelor picioare n oglinda, unul n valg, cellalt n

varus metatarsus adductus extensie permanent a halucelui sau grasping

permanent.4. Activitate motorie anormal: n DD micri generale srace, mai ales n

privina variaiei spaiale (combinaii de exie-exten-sie, adducie-abducie, rotaie intern-extern)

micrile sunt stereotipe, monotone. contracii simultane a muchilor agoniti i

antagoniti - micri n bloc.5. Examenul senzorial:Interaciunea vizual: contrastul alb-negru solicit mai mult privi-

rea n.n. prematur, deci se va olosi ochiul de bou (cer-curi concentrice alb-negru)

se poate observa absena xrii sau a urmririicu privirea

privirea n apus de soare, strabism, nistagmus eventual amimie.

Interaciunea auditiv: absena modicrii mimicii la zgomot.

6. Evaluarea descoperirii spaiului mn - gur: poziia scrimerului meninut mult timp

conduce la un risc ortopedic: riscul unei plagiocealii parieto-occipitale riscul apariiei unui hemisindrom i desco-

perirea preerenial a minii occipitale.7. Evaluarea suptului si deglutitiei. (Larroque, Leroy)ncepnd cu a 34-a sptmn de gestaie, se ma-

turizeaz coordonarea suptului si deglutiiei n cele 3

aze: oral, aringian i esoagian. la 34 sptmni VC se poate examina reexulde cutare al snului, innd capul copilului n uoarexie i cu degetul atingem aa copilului n dreptullobului urechii pn la comisura bucal, provocndorientarea buzelor n acea direcie.

La prematuri putem observa: absena reexului de cutare a snului, sau al

suptului reexul de supt exist, dar copilul nu nghite

suptul i deglutiia exist, dar cu incoordonarearingo-esoagian perturbri ale deglutiiei datorit dicultilor


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respiratorii

hipomobilitate a serei bucale, gura e beant,limba hipoton stimularea serei bucale antreneaz opistoto-

nus.8. Bilanul motor i ortopedic (Pinol, Grenier)La noul nscut prematur: se constat grasping absent sau asimetric la traciunea din DD copilul se arunc n ex-

tensie sau extinde MI i se ridica n ortostatism de asemeni, la aceast manevr exist deze-

chilibru ntre cuplul agoniti-antagoniti capul rmne nclinat ntr-o parte. provocnd rostogolirea din DD n DV de la

nivelul MI se observ: anomalii tonice ale MI care mpiedic manevra extensie i asimetrie a rotaiei capului atitudinea MS n candelabru, extensie a trun-

chiului un MS rmne n rotaie intern, nu se dega-jeaz (isson, Metayer)

din DL, realiznd reacia lateral de abducie,

nu se produce abducia coapsei MI supralateral odat

cu exia lateral a capului. (Grenier)O reacie normal Grenier a n.n. reprezint un

prognostic oarte bun din punct de vedere motor.(Fig. 6 - Reacia lateral de abducie Grenier)

n suspensie subaxilar:

copilul nu se poate menine, se scurge printreminile terapeutului lsat suspendat cu picioarele pe planul me-

sei, picioarele se poziioneaz n echin, sauun picior n varus, celalalt n valgus (Fig. 7 Poziionarea picioarelor n echin)

sau se poate observa un grasping permanent al

degetelor picioarelor. (Leroy, Pinol) n suspensie ventral: - hipotonie axial important n eznd la marginea mesei: la dezechilibrrile

laterale, mna de partea nclinrii nu ia sprijin pemas, iar MI controlateral nu se orienteaz-abducie,piciorul rmne n varus-echin sau talus-valg. (Fig. 8 Dezechilibrare lateral incorect)

Fig. 8 - Dezechilibrare lateral incorect.

n eznd cu MI pe planul mesei se observ: asimetrii ale abduciei MI, sau un MI este n

rotaie intern i adducie, celalalt n pozie neutr.

Fig. 7 - Poziionarea picioarelor n echin

Fig. 6 - Reacia lateral de abducie Grenier

Fig. 9 - n ghemuit defciene ale poziiei picioarelor


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copilul ade asimetric, cu sprijin mai mult peo es.

poziionat n ghemuit: copilul nu-i susine greutatea

picioarele se poziioneaz asimetric, iar lamicrile n lateral induse de terapeut, nu apareinversia-eversia normal (Metayer) (Fig. 9 n

ghemuit defciene ale poziiei picioarelor) mobilizarea pasiv a MS n DD: hiperpronaie a antebraelor, pumnul nchis police addus

mobilizarea pasiv a MI: hipertonie a muchilor posteriori ai centurii

pelvine constatat la exia bazinului. (Fig. 10 Flexia bazinului pe abdomen)

din DD, exia la 90 grade a coapselor cu exten-sia genunchilor relev o asimetrie a deschideriiunghiului popliteu. n acelai timp se poate ob-serva i poziia picioarelor n valgus sau varus.(Fig. 11 Aprecierea asimetriei unghiului popliteu)

exist un deect de extensibilitate a grupelor

musculare poliarticulare ale oldurilor i ge-nunchilor

la nclinrile capului la dreapta i stnga se ob-serv asimetrie, cu ridicarea de asemenea asi-

metric a umrului nu n ultimul rnd, reaciile de postur Vojtabinecunoscute, ac parte din bateria de teste utilizatde kinetoterapeut.

di i (l, a. ti) plagiocealie torticolis hiperpronaie a MS exie cubital a pumnilor pumn nchis

police addus atitudine scoliotic n C dezechilibru al bazinului n plan rontal instabilitate coxo-emural genu exum genu recurvatum picior echin picior n varus sau valgus

** *

Fig. 10 - Flexia bazinului pe abdomen Fig. 11 - Aprecierea asimetriei unghiului popliteu

It is well-known the act that the decrease in in-antile mortality was not ollowed by the concomitantdecrease in morbidity, on the contrary, there was anincrease in prevalence o neurosensory deciencies.Due to technical progress concerning the care o pre-mature babies or o those with a very low weight atbirth, they survive but there are numerous cases withmany neurosensory deciencies.T fii(lq, v):

Babies born in term with weight > 2500g. 1/1000Babies born between 32 and 36 weeks, weight: 1500-2500g. 1%Babies born under 32 weeks, weight < 1500g. 6%

Te Surveillance o Cerebral Palsy in Europe(SCPE) collaborative group has concluded that at theage o 5 years old:

- 31% o the above cases do not walk independently;- 16% walk only with help;- 53% walk independently.

Iii i fii i :

Prematurity < 32 gestation weeks, Weight at birth < 1500g ,

Intrauterine growth delay, Gestational hypertension, Pre or perinatal inections,


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general study robnescu ligia importance of precocous sensory motor assessment by the knesotherapst...

33Journal of Romanian Child and Adolescent Neurology and Psychiatry 2012 15thvol. no. 2

Multiple births, possibly ollowed by prematu-rity,

Perinatal asphyxia, Rh incompatibility, Prevalence o the masculine gender in pre-

mature babies.Irrespective its gestational age and weight, any ne-wborn with a moderate or severe pathology will be su-pervised attentively rom the ollowing points o view:

Neurosensory, psychomotor, Growth, respiratory and digestive pathology, Psychology behaviour, sleep, Social amilial, Language communication.

exii i ii

(bi): 0 1year: at birth, at 40 gestational weeks, at3 months, at 4 months, 6 months, 9 months correctedage (CA);

1 - 2 years: 12 months, 18 months, 24 monthsCA;

3 - 6 years: annually.Te assessment o the kinetotherapist may begin

starting with the 37th week o CA.Whichever the case, ater leaving the maternity

hospital, it is very important that the amily physicianshould assume the supervision o the child, and guidethe amily to the neurologist and to the centres speci-alised in rehabilitation treatments.cii xii .

Te neurosensory development is the result o thecombined inuence o genetic actors and o the en-

vironment, which accomplish the most efcient pat-terns o movement. Te motor skills o the ull-termnewborn baby are characterised by:

axial hypotonia

limb hypertonia archaic reexes complex and variable spontaneous motor ac-

tivity.p :

During the last trimester o gestation, the oetus,being positioned with its back to the uterine wall, hasa tendency to exion. Te preterm, who does not ex-perience this intrauterine period, is hypotonic, cannotregroup spontaneously (Bullinger, Ros)

Te absence o regrouping possibility has theollowing consequences: It avours an asymmetric posture, prevents

the rotation o the chest and prevents the inant tolook at his/her hands, too. (Ferraud)

It is necessary to position the baby in exion(oetal posture) in order to initiate a visual, auditory

relationship and in order to calm down the inant. Extension as a pattern predominates, as well

as the asymmetric posture, disturbing the neuro-motoracquisitions, especially the evolution towards symmetry.

Te body diagram evolves into the triad: pla-giocephaly, alse torticollis hemisyndrome, a situationthat is aggravated in the case o neurologic lesions.

Many preterm babies maintain the rog-likeposture due to muscular hypotonia and poor sponta-neous movements. (Fig.1 - rog-like posture)

In this situation, iliac, psoas and middle adductormuscles are shortened, avouring an internal rotation

Fig. 1 - Frog-like posture (ater Amiel-isson )

Fig. 2 Correct posturing o preterm baby - Amiel-isson


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34 Journal of Romanian Child and Adolescent Neurology and Psychiatry 2012 15thvol. no. 1

o emoral diaphysis and the possibility o anteriordislocation o the emoral head. Te neonatologistsduty is to assure a physiologic posture since the rstday, with thighs in slight abduction, the knees in semiexion, above the level o the bed. (Fig. 2 Correct

posturing o preterm baby) Te poor motor activity xes the muscles inshortened positions, thus they lose their extensibility.

For example, the chandelier posture o the

lower limbs is due to the shortening o the superior tra-peze muscle or the shearing o the lower limbs by hy-pertonia o the adductors. (Fig. 3 Chandelier posture)

Fig. 3 Chandelier Posture (according to Pinol B)

Tus, the preterm baby needs realignment in e-xion in order to express its motility when it is positi-

oned correctly.Besides the examination perormed by the neona-tologist, the kinesiotherapist will perorm a clinicalexamination o the inant when there are no longercritical problems.

It will be an examination: Additional to the medical one; It should rst

be perormed in hospital starting with the age o 34weeks CA.

Re-examination at 3 months CA will con-

rm or inrm the neuromotor development anoma-lies (Pinol, Ros) Further periodical re-examinations.

Tis assessment by the kinesiotherapist requires: Close contact with the childs parents, in-

structing them to position the inant correctly and tomobilize it or improved mobility and eeding, namely

a perioral stimulation that will improve the e-

eding difculties, as well as the slight exiono the head, which will acilitate cervical para-

vertebral muscle stress relieve and thereore the

swallowing reex. (Grenier) rocking the baby in a oetal position to be used

up to 3 - 4 months CA. (Fig. 4 - Rocking thebaby in oetal position.)

Fig. 4 - Rocking the baby in oetal position.

positioning the baby in Recamier postureallows or the inants liberation eeling by

giving support to its head. Tus, the motilityloses its reex character, the uncontrollable

movements disappear, the child calms down.(Grenier) (Fig. 5 - Recamier Posture)


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Fig. 5 - Recamier Posture

Placing the inant in a hammock increases thesleep quality and reduces the risk o deormiti-es and during the day it is advisable to place theinant in a cocoon made o sponge, to ensureexion posture. (Ferraud. Pinol).

attention should be paid to proper positioningduring suckling

position in supine or a long time can avourplagiocephaly and alse torticollis by the pre-erence o the child to maintain his/her headbent on a certain side, avouring a tonic he-micorporal asymmetry. (Captier) (False tor-ticollis = loss o extensibility o sterno-cleidomastoid muscle)

asymmetrical posture in children can osterscoliosis attitudes in C when positioning thebaby in a sitting posture.

oi ii (aiti)

What needs to be noticed in a newborn?1. a : Excessive hyperextension o the head and

sometimes o the trunk, too; A trunk inclination (scoliosis in C)

Predominant active exion o the head.2. u i: Attitude in chandelier unilateral or bilat-

eral; Wrist exion and thumb adductor .

3. l i: Attitude in extension, internal rotation, pos-

sibly shearing; Imbalance o the pelvis in the rontal plane;

Attitude in equinus o the eet ; Feet in mirror, one in valgus, the other in

varus deormity; Metatarsus adductus; Permanent extension or permanent grasping

o the hallux.4. a ii: In supine position poor general movements,

especially concerning the spatial variant (combina-tions o exion-extension, adduction-abduction, in-ternal-external rotation;

Movements are stereotyped, monotonous.

- Simultaneous contraction o agonist andantagonist muscles movements in block.

5. s xii:Visual interaction: Contrast white-black requires more atten-

tion rom the preterm newborn than, so it will use thebulls eye (white-black concentric circles)

One can see the absence o xation or o thetracking gaze Eyes in the sunset, strabismus, nystagmus Possible amimie.Hearing Interaction: Mimicry does not change when a noise is

produced.6. ei i : Fencer posture maintained or a long time,

a leading to orthopedic risk:

- Risk o parietal-occipital plagiocephaly- Risk o hemisyndrome and the preerentialdiscovery o the occipital hand.

7. ei i i.(Larroque, Leroy)

Since the 34th gestation week, sucking andswallowing coordination matures in 3 phases: oral,pharyngeal and oesophageal.

at 34 weeks AC one may examine the searcho the breast reex, holding the babys head slightlyexed and ngers touching the babys ace in the area

rom the right ear lobe to the corner o mouth, caus-ing orientation o the lips in that direction.In premature inants we may see: Absence o reex the search o the breast, or

o sucking Sucking reex is present, but the child does

not swallow Sucking and swallowing are present, but with

lack o pharyngo-esophageal coordination Disturbances o swallowing due to respira-

tory difculties Hypo-motilit o the mouth area, the mouthis open permanently, with hypotonic tongue

Oral stimulation determines opistotonus.8. m i (Pinol,

Grenier)In the preterm newborn one may notice: Absent or asymmetric grasping; At traction rom supine position, the child

throws itsel in extension or it extends the lower limbsand it gets up in orthostatism

At this manoeuvre there is an imbalance be-tween the couple o agonist and antagonist muscles


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Te head remains tilted on one side; Causing the baby to roll rom supine position

to prone position rom the level o lower limbs theollowing are noted:

tonic abnormalities o the lower limbs that

prevent the manoeuvre; extension and asymmetry o head rotation attitude o the upper limbs in chandelier, ex-

tension o the trunk; one upper limb remains in interior rotation it

does not get ree.(isson, Metayer) From lateral decubitus, while attempting the

reaction o lateral abduction, the abduction o the

upper lateral thigh does not occur at the same timewith the lateral exion o the head. (Grenier) A nor-mal Grenier reaction o the newborn has a very goodprognosis rom the motor point o view. (Fig. 6 - Gre-nier Lateral Abduction Reaction).

Fig. 6 - Grenier Lateral Abduction Reaction

In vertical suspension (being held by the ex-aminer, with his/her hands under the babys arms):

Te child cannot maintain itsel, it seems to

slip rom the examiners hands. Te child is suspended with the eet on the

table plane, its eet take the equinus postureor with one oot in varus, the other in valgus.(Fig. 7 Positioning the eet in equinus)

Fig. 7 Positioning o the eet in equinus

Or, one may note a permanent grasping o thetoes (Leroy, Pinol) in ventral suspension: - signicant axial hypo-

tonia. in sitting position on the edge o the table:

- at side imbalances, the hand on the part othe bending does not take support on thetable, and the collateral lower limb does notorient itsel in abduction; the oot remains

in varus equin or in talus valgus. (Fig. 8 Incorrect side imbalance)

Fig. 8 - Incorrect side imbalance.

In sitting position with lower limbs on thehorizontal surace one may note:

Asymmetries o lower limbs abduction or onelower limb is in internal rotation and adducti-


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on, the other in neutral position.

Te child sits asymmetrically, with moresupport on a buttock than on the other. Positioned in squat: the child does not support their weight

the eet position asymmetrically and at the lateralmovements induced by the therapist, the inver-sion-eversion is not normal (Metayer). (Fig. 9

In squat position, defciencies o the eet are assessed)

Fig. 9 In squat position, defciencies o the eet are assessed

passive mobilization o the upper limbs insupine position: hyperpronation o the orearm with the st

closed adducted thumb

passive mobilization o the lower limbs: hypertonia o the posterior pelvic muscles sub-

sequently noted in the exion o the pelvis.(Fig. 10 Flexion o the pelvis on the stomach) From supine position, the 90 degrees exion

o the thighs with the extension o the kne-es reveals an asymmetry o the opening o thepopliteal angle. At the same time, one may alsonote the varus or valgus position o the eet.

(Fig. 11 Assessment o the asymmetry o the po-

pliteal angle) there is a malunction o extensibility o thepolyarticular muscle groups o the hips andknees

one may note asymmetry at tilting the head tothe right and to the let, with asymmetric li-ting o the shoulder, too.

Last but not least, the well-known Vojitapostural reactions belong to the test battery used bythe kinesiotherapist .

oi ii (l, a. ti) plagiocephaly torticollis hyperpronation o the upper limbs cubital exion o the sts

closed st adducted thumb scoliosis attitude in C imbalance o the pelvic girdle in rontal plane

coxoemoral instability genu exum

genu recurvatum equin cluboot oot in varus or valgus

Fig. 10 Flexion o the pelvis on the stomach Fig. 11 Assessing the asymmetry o the popliteal angle

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3. Bullinger A. 2004. Les items dun bilan sensori-moteur.Perspectives thoriques pour ltude de development sen-sori-moteur. In : le development sensori-moteur de lenantet ses avatars. Ed.Ers, Ramonville Saint Agne, p. 23-47,

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4. Captier G.,Bigorre M, Leboncq N, Montoya R 2005.Relation entre la deormation crnienne et les anomaliescervicales, dans les plagiocephalies positionnelles. Kinesi-therapie, les annals. 46: 35-40.

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7. Larroque B, Ancel PY, Marret S, Marchand L, Andr M,Arnaud C,Pierrot V, Ros JC, Messer J, Tiriez G, Bur-guet A, Picaud JC, Brart G, Kaminski M. 2008. Epipage

study group.Neurodevelopmental disabilities and specialcare o 5-year- old children born beore 33 weeks o gesta-tion (the Epipage study) : a longitudinal cohort study. Lan-cet; 371: 813-20.

8. Leroy - Malherbe V. 2004. Enant premature et troublede la motricit. In: Motricit. 19me sminaire Guigoz.Groupe dtudes en Nonatologie- Ile de France. Ed. Labo-ratoires Guigoz, Deauville, 7-9 nov: 63-92.

9. Le Metayer M. 1993. Le dveloppement de lenant. In:Reducation crbro-motrice du jeune enant. Educationthrapeutique, kinsitherapie pdiatrique, Fausser C etVinonC. Ed. Masson Paris, p. 15-44.

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