Comprehensive Pediatric Neurology & Therapy Reference

1. Palmer (Palmar) Reflex

• Stimulus: Pressure applied to the palm
• Response: Finger flexion and grasping
• Normal persistence: Birth to 4–6 months
• Clinical significance: Persistence beyond 6 months suggests upper motor neuron dysfunction or cerebral palsy. Asymmetric response may indicate hemiplegia.

2. Moro Reflex

• Stimulus: Sudden head drop, loud noise, or sudden movement
• Response (3 phases):
  1. Arm abduction and extension with finger spreading
  2. Arm adduction (embrace)
  3. Cry
• Normal persistence: Birth to 4–6 months
• Absence at birth: Suggests birth asphyxia, brain injury, or spinal cord injury
• Asymmetric response: Indicates Erb's palsy, clavicle fracture, or hemiplegia
• Persistence beyond 6 months: Suggests CNS pathology

Four Therapeutic Effects of 1st SEMT (Sensory Motor Exercise/Moro Therapy):

1. Integration of the retained Moro reflex, reducing hyperreactivity
2. Improved postural stability and equilibrium reactions
3. Reduced sensory hypersensitivity and enhanced self-regulation
4. Enhanced development of higher cortical inhibitory pathways, supporting attention and learning

3. Primitive Reflexes — Definition & Classification

Definition

Classification

4. Parachute Reflex

• Stimulus: Infant held upright and tilted forward toward a surface (or moved suddenly downward)
• Response: Arms extend, hands open, and fingers spread as if to break a fall
• Onset: ~6–9 months (downward parachute by 6 months; forward by 7–9 months)
• Persistence: Lifelong — it is a mature protective response
• Clinical significance: Absence or asymmetry suggests CP, hemiplegia, or brachial plexus injury. It is a key milestone in neuromotor development assessment.

5. Dystonia

Features:

• Twisting, repetitive movements or fixed abnormal postures
• Can affect one body part (focal) or multiple (generalized)
• Worsened by voluntary movement (action dystonia) and stress
• May be sustained or phasic

Types in CP context:

• Primary (idiopathic) dystonia: No identifiable cause
• Secondary dystonia: Due to known cause (e.g., hypoxic-ischemic injury in CP, kernicterus)
• Dyskinetic CP features dystonia and/or choreoathetosis

6. Chorea (Korea — likely "Chorea")

• Brief, purposeless, unpredictable movements
• "Dance-like" quality
• Disappears during sleep
• Common in: Huntington's disease, Sydenham's chorea, dyskinetic CP, kernicterus
• In CP: often combined with athetosis → choreoathetosis

7. Cerebral Palsy (CP) — Definition

8. Types of Cerebral Palsy

Subtypes of Spastic CP:

• Hemiplegia: One side of body
• Diplegia: Bilateral LE > UE (classic in premature infants)
• Quadriplegia/Tetraplegia: All four limbs, often with intellectual disability

9. Clinical Features of Cerebral Palsy (4 Common)

1. Abnormal muscle tone — spasticity (most common), hypotonia, or fluctuating tone
2. Delayed motor milestones — delayed head control, sitting, standing, walking
3. Persistence of primitive reflexes — beyond normal age of integration (e.g., ATNR, Moro)
4. Abnormal movement patterns — scissor gait, toe-walking, involuntary movements, poor coordination

10. Characteristic Features of Ataxic Cerebral Palsy

• Wide-based gait (cerebellar ataxia)
• Intention tremor — tremor on purposeful movement
• Dysmetria — inability to judge distance/force (overshoot/undershoot)
• Hypotonia — low muscle tone
• Dysarthria — slurred, scanning speech
• Dysdiadochokinesia — impaired rapid alternating movements
• Nystagmus may be present
• Poor balance and coordination
• Accounts for ~5–10% of CP cases; often associated with consanguinity or genetic causes

11. Spasticity — Definition

Key Features:

• Velocity-dependent resistance to passive stretch
• "Clasp-knife" phenomenon (initial resistance then sudden release)
• Hyperreflexia and clonus
• Associated with corticospinal tract lesions
• Leads to contractures, deformity, and functional limitation in CP

12. Impaired Muscle Synergy

• In upper motor neuron lesions (e.g., CP, stroke), movements are dominated by abnormal synergy patterns rather than selective motor control
• Flexor synergy (UE): shoulder abduction/external rotation, elbow flexion, forearm supination, wrist/finger flexion
• Extensor synergy (LE): hip extension/adduction/internal rotation, knee extension, ankle plantarflexion/inversion
• These stereotyped patterns limit functional independence
• NDT (Neurodevelopmental Treatment) specifically targets breaking up these abnormal synergies

13. Hypotonia (Described as "Photonia/Dystonia" — likely Hypotonia)

Features:

• Poor head control, "rag doll" posture
• Excessive joint mobility
• Frog-leg posture in supine
• Delayed motor milestones
• Weak cry and feeding difficulties in neonates

Causes in pediatrics:

• Central (brain/spinal cord): CP, Down syndrome, hypothyroidism
• Peripheral (muscle/nerve): Spinal muscular atrophy, muscular dystrophy, myasthenia gravis
• "Central hypotonia" is common in early CP before spasticity emerges

14. Syringomyelia (Described as "Spirngo Mylia")

Features:

• Cape-like distribution of pain and temperature loss (bilateral UE, shoulders, neck)
• Preservation of touch and proprioception (dissociated sensory loss)
• Progressive weakness and wasting of intrinsic hand muscles
• Later: spastic paraparesis, bowel/bladder dysfunction
• Causes: Chiari malformation (most common), post-traumatic, tumors, idiopathic

In Pediatrics:

• Often associated with Chiari I malformation
• Presents with scoliosis, neck pain, hand weakness
• MRI spine is diagnostic

15. Down Syndrome

Features:

• Facial: Upslanting palpebral fissures, epicanthal folds, flat nasal bridge, small ears, macroglossia
• Hypotonia (universal)
• Intellectual disability (mild to moderate)
• Short stature
• Atlantoaxial instability
• Cardiac defects (40–50%): AVSD, VSD, ASD
• GI: Duodenal atresia, Hirschsprung's disease
• Dermatoglyphics: Single palmar crease (simian crease), clinodactyly
• Risk of leukemia (ALL, AML), hypothyroidism, early-onset Alzheimer's

Karyotype:

• 47 chromosomes; extra chromosome 21
• Types: Nondisjunction (95%), Translocation (4%), Mosaic (1%)

16. Sensory Integration Therapy

Definition:

Principles:

1. Just-right challenge — activities are tailored to be achievable yet challenging
2. Child-directed activity — child's inner drive/motivation guides the session
3. Adaptive response — child produces appropriate responses to sensory-motor challenges
4. Active participation — child is an active participant, not passive recipient
5. Sensory-rich environment — equipment provides proprioceptive, vestibular, tactile input
6. Therapeutic relationship — therapist follows the child's lead

Therapeutic Effects of Sensory Integration Therapy:

1. Improved sensory processing and modulation
2. Enhanced motor planning (praxis) and coordination
3. Better attention, self-regulation, and behavioral organization
4. Improved functional performance in daily activities
5. Reduced tactile defensiveness and hypersensitivity
6. Development of postural control and balance

Complications/Considerations in Sensory Stimulation for CP:

• Risk of sensory overload or autonomic dysreflexia if stimulation is too intense
• Seizure precipitation with certain sensory stimuli (especially in epileptic CP)
• Adverse behavioral responses (agitation, self-injurious behavior)
• Habituation — therapeutic benefit reduces with repetitive, non-varied stimulation
• Sensory hypersensitivity may worsen with poorly graded input

Sensory Systems in Children with CP:

• Tactile system: Tactile defensiveness, poor two-point discrimination
• Proprioceptive system: Impaired body awareness, poor joint position sense
• Vestibular system: Balance and postural control deficits
• Visual system: Strabismus, cortical visual impairment
• Auditory: Hearing loss (especially in dyskinetic CP from kernicterus)

17. Early Intervention

Definition:

Need for Early Intervention:

1. Neuroplasticity — the developing brain has maximal capacity for reorganization in early years
2. Prevention of secondary complications — contractures, deformity, behavioral issues
3. Family support and education — empowers caregivers as primary therapists
4. Critical/sensitive periods — sensory, motor, and language development windows exist
5. Cost-effectiveness — early treatment reduces lifetime disability burden
6. Better functional outcomes — earlier intervention = greater motor and cognitive gains

Principles of Early Intervention:

1. Family-centered care — family as equal partners
2. Natural environments — services in home/community settings
3. Individualized and strengths-based
4. Evidence-based and multidisciplinary
5. Developmentally appropriate
6. Regular reassessment and outcome measurement
7. Transition planning

18. CIMT — Constraint-Induced Movement Therapy

Definition:

Indications:

1. Hemiplegic CP with functional use of affected arm (≥10° wrist/20° finger extension)
2. Learned non-use of hemiplegic limb
3. Post-stroke hemiplegia in children
4. Unilateral brachial plexus injury
5. Children aged ≥2 years with sufficient cognitive ability to participate

Contraindications:

• Severe spasticity (MACS V)
• Fixed contractures of affected limb
• Severe cognitive/behavioral problems affecting compliance
• Active seizure disorder

5 NDT (Neurodevelopmental Treatment) Principles:

1. Handling techniques — therapist uses key points of control to inhibit abnormal tone and facilitate normal movement
2. Inhibition — reduction of abnormal spasticity and reflex patterns
3. Facilitation — promoting normal postural reactions (righting, equilibrium, protective)
4. Preparation — normalizing tone before functional activity
5. Carryover and 24-hour management — consistent positioning and handling throughout the day, not just during therapy sessions

19. Pediatric Assessment

Aim and Objectives of Pediatric Examination:

1. Determine the child's current level of developmental, motor, sensory, and functional ability
2. Identify impairments, activity limitations, and participation restrictions (ICF framework)
3. Establish a baseline for measuring progress
4. Guide treatment planning and goal setting
5. Monitor response to intervention
6. Provide information for family counseling and education

Objective of Assessment in Pediatrics (Aman Objective):

• A — Assess developmental milestones
• M — Measure functional abilities and limitations
• A — Analyze abnormal movement patterns and tone
• N — Note family, social, and environmental factors

Components of Pediatric Examination:

1. History — Birth history, developmental history, medical/surgical history, family history
2. General observation — Posture, movement, behavior, facial features
3. Developmental assessment — Gross motor, fine motor, language, social, adaptive (GMFCS, Bayley, Denver)
4. Neurological examination — Tone, reflexes (primitive and postural), coordination, sensation
5. Musculoskeletal assessment — ROM, joint alignment, muscle strength, deformities
6. Functional assessment — ADL, mobility, self-care (GMFCS, MACS, CFCS)
7. Sensory assessment — Sensory processing, visual, hearing
8. Standardized tools — see below

4 Common Screening Tools in Pediatric Examination:

1. Denver Developmental Screening Test II (DDST-II) — screens gross motor, fine motor, language, personal-social development (birth–6 years)
2. Gross Motor Function Classification System (GMFCS) — classifies severity of motor limitation in CP (Levels I–V)
3. Ages and Stages Questionnaire (ASQ) — parent-completed developmental screening tool
4. Bayley Scales of Infant and Toddler Development (Bayley-III/IV) — standardized assessment of cognitive, language, motor development

20. Neurodevelopmental Treatment (NDT)

Definition:

Examination of Complications Seen in CP (NDT Framework):

• Abnormal muscle tone (spasticity, hypotonia, fluctuating)
• Retained primitive reflexes interfering with function
• Absence/delay of postural reactions (righting, equilibrium, protective)
• Abnormal movement synergies
• Contractures and bony deformities
• Sensory deficits
• Feeding and oral motor difficulties

Quick Reference Summary Table