Referat general

Robnescu Ligia Importana evalurii precoce senzitivo-motorii a nou nscutului cu risc de ctre kinetoterapeut Referat general

Importana evalurii precoce senzitivo-motorii a nou nscutului cu risc de ctre kinetoterapeut Importance of precocious sensory motor assessment by the kinesiotherapist of the risk new-born baby Robnescu Ligia1, Bojan Cristina2, Coltos Mirela3, Cosac Elena4
Rezumat Scderea mortalitii perinatale nu a fost urmat de o scdere concomitent a morbiditii, ci a survenit chiar o cretere a prevalenelor deficienelor motorii i senzitive. Graie progresului tehnic privind ngrijirea perinatal a copiilor prematuri sau cu greutate foarte mic la natere, acetia supravieuiesc, dar apar cazuri mai multe cu deficit neurosenzorial. n orice caz, indiferent de vrsta gestaional i de greutate, orice nou nscut cu o patologie sever sau moderat, necesit o supraveghere atent de ctre neonatolog, realizndu-se bilanuri neuromotorii la natere i apoi la intervale regulate, iar bilanul kinetoterapeutului se poate face ncepnd cu vrsta corectat de 34 sptmni. Aceasta evaluare nu se substitue examenului medical (clinic, imagistic, EEG, poteniale evocate vizuale i auditive etc,), ci constitue 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 of perinatal mortality has not been followed by a concomitant reduction of morbidity; on the contrary, there is a rise in the prevalence of motor and sensory deficiencies. Thanks to the technological progress in perinatal care of the premature infants or of those with a very low weight at birth, they survive indeed but there are a lot of cases with neurosensory deficit. Anyway, in spite of its gestational age and of its weight, any new-born infant with severe or moderate pathology, requires attentive supervision by the neonatologist so that neuromotor assessments are performed first at birth, then at regular intervals, and the kinesiotherapist assessment may be performed starting with the corrected age of 34 weeks. This 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 of the infant. The aim is to stimulate the infant early so as to reduce the possible handicap concomitant with the training of the parents for the positioning and the mobilization of the new-born infant. Key words: new-born infant at risk, prematurity, kinesiotherapist, early assessment
1 2, 3, 4

Medic specialist recuperare medical, Bucureti Kinetoterapeut, Bucureti

2, 3, 4

MD, medical rehabilitation, Bucharest Kinetotherapist, Bucharest

Adres coresponden: Spitalul Clinic de Psihiatrie Prof. Dr. Alexandru Obregia - Bucureti Clinica de Neuropediatrie os. Berceni, Sector 4 Bucureti

Correspondence address: Hospital Prof. Dr. Al. Obregia Bucharest Clinic of Paediatric Neurology Berceni street, Sector 4 Bucharest

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Este cunoscut faptul c scderea mortalitii infantile nu a fost urmat de scderea concomitent a morbiditii, ci a survenit chiar o cretere a prevalenei deficienelor neurosenzoriale. Graie progreselor tehnice privind ngrijirea copiilor prematuri sau cu o greutate foarte mic la natere, acetia supravieuiesc, dar apar cazuri mai multe cu deficiente neurosenzoriale. Prevalena acestor deficiene (Larroque, Vohr)
nscui la termen cu greutate > 2500 g. 1/1000 nscui ntre 32-36 sptmni, greutate 1500-2500g. 1% nscui sub 32 sptmni, greutate < 1500g 6%

Grupul de Supraveghere European al Paraliziei cerebrale conchide c: la vrsta de 5 ani:  31% din cazurile de mai sus nu merg independent 16% se deplaseaz cu ajutor 53% merg independent Factori de risc intrinseci ai deficienelor neurosenzoriale ale nou-nscutului: Prematuritatea < 32 sptmni de gestaie Greutatea la natere < 1500g. ntrzierea n creterea intrauterin Hipertensiunea gestaional Infecii pre sau perinatale Nateri multiple, dup care poate apare prematuritatea Asfixia perinatal Incompatibilitatea Rh Prevalena sexului masculin la prematuri. Indiferent de vrsta gestaional i greutate, orice nou nscut (nn) cu o patologie moderat sau sever, va fi atent supraveghiat dpdv: neurosenzorial, psihomotor cretere, patologie respiratorie i digestiv psihologic - comportamental-somn sociofamilial 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 ncepnd cu 34 sptmni VC. n orice caz, dupa externarea din maternitate, este foarte important ca medicul de familie s preia ur28

mrirea copilului, urmnd s ndrume familia ctre neurolog i ctre centrele specializate n tratamentul de reabilitare. Examenul clinic al nou nscutului Dezvoltarea neuromotorie este rezultatul influen ei combinate a factorilor genetici i de mediu, care desavresc schemele cele mai eficiente de micare. Aptitudinile motrice ale n.n. la termen sunt caracterizate prin: hipotonie axial hipertonie membre reflexe arhaice activitate motric spontan complex i variabil. Nou nscutul prematur: n ultimul trimestru de gestaie, fetusul poziionat cu spatele la peretele uterin, are tendina la flexie. Prematurul, care nu traverseaz aceast perioad intrauterin, este hipoton, nu se poate regrupa spontan. (Bullinger, Ros) Absena posibilitii de regrupare are consecine: favorizeaz o postur asimetric, mpiedic rotaia bustului i deasemeni mpiedic sugarul s-i priveasc minile. (Ferraud) este necesar poziionarea copilului n flexie (poziie fetal) pentru a iniia o relaie vizual, auditiv i pentru a obine calmarea sugarului. predomin schema n extensie, ca i poziia asimetric, perturbnd achiziiile neuromotorii, mai ales evoluia spre simetrie. schema corporal evolueaz n triada: plagiocefalie, fals torticolis, hemisindrom, situaie agravat n cazul leziunilor neurologice. muli prematuri se menin n poziia de ba-

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

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

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Robnescu Ligia Importana evalurii precoce senzitivo-motorii a nou nscutului cu risc de ctre kinetoterapeut

n aceasta situaie, psoas iliacul i adductorul mijlociu sunt scurtai, favoriznd o rotaie intern a diafizelor femurale i posibilitatea de luxaie anterioar a capului femural. Sarcina neonatologului este de a asigura din prima zi o postur fiziologic, cu coapsele n uoar abducie, genunchii n semiflexie, deasupra planului patului.

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

(Fig. 2 - Posturarea corecta a prematurului)

Fig. 2 - Posturarea corect a prematurului (Amiel-Tisson)

activitatea motric insuficient fixeaz muchii n poziii scurtate, astfel acetia i pierd extensibilitatea. de exemplu, poziia n candelabru a membrelor superioare datorit scurtrii trapezului superior, sau forfecarea membrelor inf. prin hipertonia adductorilor. (Fig. 3 - Postura n candelabru) Deci prematurul are nevoie de regrupare n flexie pentru a-i exprima motilitatea cnd este corect poziionat. n afara examenului efectuat de neonatolog, kinetoterapeutul va face un examen clinic al copilului, n momentul cnd nu mai exist probleme cririce. Va fi un examen: complementar celui medical. Aceasta evaluare ar trebui efectuat n maternitate ncepnd cu vrsta de 34 sptamni VC Reexaminarea la 3 luni VC va confirma sau va infirma anomaliile de dezvoltare neuromotorii. (Pinol, Ros) Reexaminri ulterioare periodice

Aceasta evaluare a kinetoterapeutului presupune: o legtura strns cu prinii copilului, instruindu-i pentru poziionarea i mobilizarea sugarului, pentru ameliorarea mobilitii i a alimentaiei i anume: stimularea perioral care va ameliora dificul t ile de alimentaie, ca i uoar flexie a capului, ceea ce va favoriza distensia musculaturii paravertebrale cervicale i deci reflexul de deglutiie. (Grenier)

legnarea n poziie fetal care va fi folosit pn la 3 - 4 luni VC. (Fig. 4 - Legnarea n poziie fetal.)
Fig. 4 - Legnarea n poziie fetal

poziionarea n postura Recamier permite 29

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starea de eliberare a sugarului prin susinerea capului. Astfel, motricitatea i pierde caracterul reflex, dispar micrile necontrolabile, copilul se linitete. (Grenier) (Fig. 5 - Postura recamier)
Fig. 5 - Postura recamier

instalarea n hamac crete calitatea somnului i diminueaz riscul deformaiilor, iar n timpul zilei este indicat poziionarea ntr-un cocon confecionat din buret, pentru a asigura postura n flexie. (Ferraud. Pinol) atenie la poziionarea corect n timpul suptului postura ndelungat n DD poate favoriza plagiocefalia i falsul torticolis prin preferina copilului de a-i menine capul nclinat pe o anumit parte, favoriznd o asimetrie tonic hemicorporal. (Captier) (Falsul torticolis = pierderea extensibilitatii sterno-cleido-mastoidianului) postura asimetric a copilului poate favoriza atitudini scoliotice n C cnd poziionm sugarul n eznd. Observaia posturii i activitatea motorie spontan (Amiel -Tisson) 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 flexiei active a capului. 2. Membre superioare: atitudine n candelabru uni sau bilateral flexie a pumnilor i adducia policelui 3. Membre inferioare: 30

atitudine n extensie, rotaie intern, eventual forfecare dezechilibru al bazinului n plan frontal 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 flexie-extensie, 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 privirea n.n. prematur, deci se va folosi ochiul de bou (cercuri concentrice alb-negru) se poate observa absena fixrii sau a urmririi cu privirea privirea n apus de soare, strabism, nistagmus eventual amimie. Interaciunea auditiv: absena modificrii mimicii la zgomot. 6. Evaluarea descoperirii spaiului mn - gur: poziia scrimerului meninut mult timp conduce la un risc ortopedic: riscul unei plagiocefalii parieto-occipitale  riscul apariiei unui hemisindrom i descoperirea preferenial a minii occipitale. 7. Evaluarea suptului si deglutitiei. (Larroque, Leroy) ncepnd cu a 34-a sptmn de gestaie, se maturizeaz coordonarea suptului si deglutiiei n cele 3 faze: oral, faringian i esofagian. la 34 sptmni VC se poate examina reflexul de cutare al snului, innd capul copilului n uoar flexie i cu degetul atingem faa copilului n dreptul lobului urechii pn la comisura bucal, provocnd orientarea buzelor n acea direcie. La prematuri putem observa: absena reflexului de cutare a snului, sau al suptului reflexul de supt exist, dar copilul nu nghite suptul i deglutiia exist, dar cu incoordonare faringo-esofagian perturbri ale deglutiiei datorit dificultilor

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Robnescu Ligia Importana evalurii precoce senzitivo-motorii a nou nscutului cu risc de ctre kinetoterapeut

cu flexia lateral a capului. (Grenier) O reacie normal Grenier a n.n. reprezint un prognostic foarte bun din punct de vedere motor. (Fig. 6 - Reacia lateral de abducie Grenier) n suspensie subaxilar: copilul nu se poate menine, se scurge printre minile terapeutului lsat suspendat cu picioarele pe planul mesei, picioarele se poziioneaz n echin, sau un picior n varus, celalalt n valgus (Fig. 7 Poziionarea picioarelor n echin) sau se poate observa un grasping permanent al
Fig. 6 - Reacia lateral de abducie Grenier

respiratorii hipomobilitate a sferei bucale, gura e beant, limba hipoton stimularea sferei bucale antreneaz opistotonus. 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 extensie sau extinde MI i se ridica n ortostatism de asemeni, la aceast manevr exist dezechilibru 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 trunchiului un MS rmne n rotaie intern, nu se degajeaz (Tisson, Metayer) din DL, realiznd reacia lateral de abducie, nu se produce abducia coapsei MI supralateral odat

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 pe mas, 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. 9 - n ghemuit deficiene ale poziiei picioarelor

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Fig. 10 - Flexia bazinului pe abdomen

copilul ade asimetric, cu sprijin mai mult pe o fes. poziionat n ghemuit: copilul nu-i susine greutatea picioarele se poziioneaz asimetric, iar la micrile n lateral induse de terapeut, nu apare inversia-eversia normal (Metayer) (Fig. 9 n ghemuit deficiene 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 flexia bazinului. (Fig. 10 Flexia bazinului pe abdomen) din DD, flexia la 90 grade a coapselor cu extensia genunchilor relev o asimetrie a deschiderii unghiului popliteu. n acelai timp se poate observa i poziia picioarelor n valgus sau varus. (Fig. 11 Aprecierea asimetriei unghiului popliteu) exist un defect de extensibilitate a grupelor * * *

Fig. 11 - Aprecierea asimetriei unghiului popliteu

musculare poliarticulare ale oldurilor i genunchilor la nclinrile capului la dreapta i stnga se observ asimetrie, cu ridicarea de asemenea asimetric a umrului nu n ultimul rnd, reaciile de postur Vojta binecunoscute, fac parte din bateria de teste utilizat de kinetoterapeut. Deformri ortopedice (Leroy, A. Tisson) plagiocefalie torticolis hiperpronaie a MS flexie cubital a pumnilor pumn nchis police addus atitudine scoliotic n C dezechilibru al bazinului n plan frontal instabilitate coxo-femural genu flexum genu recurvatum picior echin picior n varus sau valgus

It is well-known the fact that the decrease in infantile mortality was not followed by the concomitant decrease in morbidity, on the contrary, there was an increase in prevalence of neurosensory deficiencies. Due to technical progress concerning the care of premature babies or of those with a very low weight at birth, they survive but there are numerous cases with many neurosensory deficiencies. The prevalence of these deficiencies (Larroque, Vohr):
Babies born in term with weight > 2500g. 1/1000 Babies born between 32 and 36 weeks, weight: 1500-2500g. 1% Babies born under 32 weeks, weight < 1500g. 6%

The Surveillance of Cerebral Palsy in Europe (SCPE) collaborative group has concluded that at the age of 5 years old: -3  1% of the above cases do not walk independently; - 16% walk only with help; - 53% walk independently. Intrinsic risk factors of the neurosensory deficiencies in the newborn baby: Prematurity < 32 gestation weeks, Weight at birth < 1500g , Intrauterine growth delay, Gestational hypertension, Pre or perinatal infections,

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Robnescu Ligia Importance of precocious sensory motor assessment by the kinesiotherapist...

Multiple births, possibly followed by prematurity, Perinatal asphyxia, Rh incompatibility, Prevalence of the masculine gender in premature babies. Irrespective its gestational age and weight, any newborn with a moderate or severe pathology will be supervised attentively from the following points of view: Neurosensory, psychomotor, Growth, respiratory and digestive pathology, Psychology behaviour, sleep, Social familial, Language communication. Examination of the child by the physician (Bournier): 0 1year: at birth, at 40 gestational weeks, at 3 months, at 4 months, 6 months, 9 months corrected age (CA); 1 - 2 years: 12 months, 18 months, 24 months CA; 3 - 6 years: annually. The assessment of the kinetotherapist may begin starting with the 37th week of CA. Whichever the case, after leaving the maternity hospital, it is very important that the family physician should assume the supervision of the child, and guide the family to the neurologist and to the centres specialised in rehabilitation treatments. Clinical examination of the newborn. The neurosensory development is the result of the combined influence of genetic factors and of the environment, which accomplish the most efficient patterns of movement. The motor skills of the full-term newborn baby are characterised by: axial hypotonia limb hypertonia archaic reflexes complex and variable spontaneous motor activity. Preterm newborn: During the last trimester of gestation, the foetus, being positioned with its back to the uterine wall, has a tendency to flexion. The preterm, who does not experience this intrauterine period, is hypotonic, cannot regroup spontaneously (Bullinger, Ros) The absence of regrouping possibility has the following consequences: It favours an asymmetric posture, prevents

Fig. 1 - Frog-like posture (after Amiel-Tisson )

the rotation of the chest and prevents the infant to look at his/her hands, too. (Ferraud) It is necessary to position the baby in flexion (foetal posture) in order to initiate a visual, auditory relationship and in order to calm down the infant. Extension as a pattern predominates, as well as the asymmetric posture, disturbing the neuro-motor acquisitions, especially the evolution towards symmetry. The body diagram evolves into the triad: plagiocephaly, false torticollis hemisyndrome, a situation that is aggravated in the case of neurologic lesions. Many preterm babies maintain the frog-like posture due to muscular hypotonia and poor spontaneous movements. (Fig.1 - frog-like posture) In this situation, iliac, psoas and middle adductor muscles are shortened, favouring an internal rotation

Fig. 2 Correct posturing of preterm baby - Amiel-Tisson

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of femoral diaphysis and the possibility of anterior dislocation of the femoral head. The neonatologists duty is to assure a physiologic posture since the first day, with thighs in slight abduction, the knees in semi flexion, above the level of the bed. (Fig. 2 Correct posturing of preterm baby) The poor motor activity fixes the muscles in shortened positions, thus they lose their extensibility. For example, the chandelier posture of the

This assessment by the kinesiotherapist requires: Close contact with the childs parents, instructing them to position the infant correctly and to mobilize it for improved mobility and feeding, namely a perioral stimulation that will improve the feeding difficulties, as well as the slight flexion of the head, which will facilitate cervical paravertebral muscle stress relieve and therefore the

swallowing reflex. (Grenier) rocking the baby in a foetal position to be used up to 3 - 4 months CA. (Fig. 4 - Rocking the baby in foetal position.)
Fig. 4 - Rocking the baby in foetal position.

lower limbs is due to the shortening of the superior trapeze muscle or the shearing of the lower limbs by hypertonia of the adductors. (Fig. 3 Chandelier posture)
Fig. 3 Chandelier Posture (according to Pinol B)

positioning the baby in Recamier posture allows for the infants liberation feeling by

Thus, the preterm baby needs realignment in flexion in order to express its motility when it is positioned correctly. Besides the examination performed by the neonatologist, the kinesiotherapist will perform a clinical examination of the infant when there are no longer critical problems. It will be an examination: Additional to the medical one; It should first be performed in hospital starting with the age of 34 weeks CA. Re-examination at 3 months CA will confirm or infirm the neuromotor development anomalies (Pinol, Ros) Further periodical re-examinations. 34

giving support to its head. Thus, the motility loses its reflex character, the uncontrollable movements disappear, the child calms down. (Grenier) (Fig. 5 - Recamier Posture)

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Fig. 5 - Recamier Posture

Placing the infant in a hammock increases the sleep quality and reduces the risk of deformities and during the day it is advisable to place the infant in a cocoon made of sponge, to ensure flexion posture. (Ferraud. Pinol). attention should be paid to proper positioning during suckling position in supine for a long time can favour plagiocephaly and false torticollis by the preference of the child to maintain his/her head bent on a certain side, favouring a tonic hemicorporal asymmetry. (Captier) (False torticollis = loss of extensibility of sterno-cleido mastoid muscle) asymmetrical posture in children can foster scoliosis attitudes in C when positioning the baby in a sitting posture. Observation of posture and spontaneous motor activity (Amiel-Tisson) What needs to be noticed in a newborn? 1. An abnormal posture: Excessive hyperextension of the head and sometimes of the trunk, too; A trunk inclination (scoliosis in C) Predominant active flexion of the head. 2. Upper limbs: Attitude in chandelier unilateral or bilateral; Wrist flexion and thumb adductor . 3. Lower limbs: Attitude in extension, internal rotation, possibly shearing; Imbalance of the pelvis in the frontal plane; Attitude in equinus of the feet ; Feet in mirror, one in valgus, the other in varus deformity; Metatarsus adductus; Permanent extension or permanent grasping of the hallux. 4. Abnormal motor activity: In supine position poor general movements, especially concerning the spatial variant (combinations of flexion-extension, adduction-abduction, internal-external rotation; Movements are stereotyped, monotonous. - Simultaneous contraction of agonist and antagonist muscles movements in block.

5. Sensory examination: Visual interaction: Contrast white-black requires more attention from the preterm newborn than, so it will use the bulls eye (white-black concentric circles) One can see the absence of fixation or of the tracking gaze Eyes in the sunset, strabismus, nystagmus Possible amimie. Hearing Interaction: Mimicry does not change when a noise is produced. 6. Evaluation of space discovery hand - mouth: Fencer posture maintained for a long time, a leading to orthopedic risk: - Risk of parietal-occipital plagiocephaly - Risk of hemisyndrome and the preferential discovery of the occipital hand. 7. Evaluation of sucking and swallowing. (Larroque, Leroy) Since the 34th gestation week, sucking and swallowing coordination matures in 3 phases: oral, pharyngeal and oesophageal. at 34 weeks AC one may examine the search of the breast reflex, holding the babys head slightly flexed and fingers touching the babys face in the area from the right ear lobe to the corner of mouth, causing orientation of the lips in that direction. In premature infants we may see: Absence of reflex the search of the breast, or of sucking Sucking reflex is present, but the child does not swallow Sucking and swallowing are present, but with lack of pharyngo-esophageal coordination Disturbances of swallowing due to respiratory difficulties Hypo-motilit of the mouth area, the mouth is open permanently, with hypotonic tongue Oral stimulation determines opistotonus. 8. Motor and orthopaedic assessment (Pinol, Grenier) In the preterm newborn one may notice: Absent or asymmetric grasping; At traction from supine position, the child throws itself in extension or it extends the lower limbs and it gets up in orthostatism At this manoeuvre there is an imbalance between the couple of agonist and antagonist muscles 35

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The head remains tilted on one side; Causing the baby to roll from supine position to prone position from the level of lower limbs the following are noted: tonic abnormalities of the lower limbs that prevent the manoeuvre; extension and asymmetry of head rotation attitude of the upper limbs in chandelier, extension of the trunk; one upper limb remains in interior rotation it does not get free.(Tisson, Metayer) From lateral decubitus, while attempting the

Fig. 7 Positioning of the feet in equinus

table plane, its feet take the equinus posture or with one foot in varus, the other in valgus. (Fig. 7 Positioning the feet in equinus)

Or, one may note a permanent grasping of the toes (Leroy, Pinol) in ventral suspension: - significant axial hypo-

tonia. reaction of lateral abduction, the abduction of the upper lateral thigh does not occur at the same time with the lateral flexion of the head. (Grenier) A normal Grenier reaction of the newborn has a very good prognosis from the motor point of view. (Fig. 6 - Grenier Lateral Abduction Reaction).
Fig. 6 - Grenier Lateral Abduction Reaction

in sitting position on the edge of the table: - at side imbalances, the hand on the part of the bending does not take support on the table, and the collateral lower limb does not orient itself in abduction; the foot remains in varus equin or in talus valgus. (Fig. 8 Incorrect side imbalance)

Fig. 8 - Incorrect side imbalance.

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

In sitting position with lower limbs on the horizontal surface one may note: Asymmetries of lower limbs abduction or one lower limb is in internal rotation and adducti-

The child cannot maintain itself, it seems to slip from the examiners hands. The child is suspended with the feet on the 36
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Fig. 10 Flexion of the pelvis on the stomach

Fig. 11 Assessing the asymmetry of the popliteal angle

on, the other in neutral position. The child sits asymmetrically, with more support on a buttock than on the other. Positioned in squat: the child does not support their weight the feet position asymmetrically and at the lateral movements induced by the therapist, the inversion-eversion is not normal (Metayer). (Fig. 9 In squat position, deficiencies of the feet are assessed)
Fig. 9 In squat position, deficiencies of the feet are assessed

passive mobilization of the upper limbs in supine position: hyperpronation of the forearm with the fist closed adducted thumb passive mobilization of the lower limbs: hypertonia of the posterior pelvic muscles subsequently noted in the flexion of the pelvis. (Fig. 10 Flexion of the pelvis on the stomach) From supine position, the 90 degrees flexion of the thighs with the extension of the knees reveals an asymmetry of the opening of the popliteal angle. At the same time, one may also note the varus or valgus position of the feet. BIBLIOGRAFIE / Bibliography:
1. Amiel-Tisson C. 1997. Maneuvers et observations a la priode nonatale et au cours de la premire anne de vie. In: L infirmit motrice dorigine crbrale. Ed. Masson. Paris; 13: p. 171-210. 2. Bonnier C.2007. Evaluation des programmes dintervention prcoce. Arch pediatr ;14 Suppl 1: 558-64.

(Fig. 11 Assessment of the asymmetry of the popliteal angle) there is a malfunction of extensibility of the polyarticular muscle groups of the hips and knees one may note asymmetry at tilting the head to the right and to the left, with asymmetric lifting of the shoulder, too. Last but not least, the well-known Vojita postural reactions belong to the test battery used by the kinesiotherapist . Orthopaedic deformities (Leroy, A. Tisson) plagiocephaly torticollis hyperpronation of the upper limbs cubital flexion of the fists closed fist adducted thumb scoliosis attitude in C imbalance of the pelvic girdle in frontal plane coxofemoral instability genu flexum genu recurvatum equin clubfoot foot in varus or valgus

3. Bullinger A. 2004. Les items dun bilan sensori-moteur. Perspectives thoriques pour ltude de development sensori-moteur. In : le development sensori-moteur de lenfant et ses avatars. Ed.Ers, Ramonville Saint Agne, p. 23-47, 191-196, 208-250.

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Robnescu Ligia Importance of precocious sensory motor assessment by the kinesiotherapist...

general study

4. Captier G.,Bigorre M, Leboncq N, Montoya R 2005. Relation entre la deformation crnienne et les anomalies cervicales, dans les plagiocephalies positionnelles. Kinesitherapie, les annals. 46: 35-40. 5. Ferraud- Serres C.2003. Le nid, de luterus la couveuse. In; Education motrice du bb risqu. J. pdiatrie et de Puriculture; 16: 68-69. 6. Grenier A. 1986. Evaluation prcoce avec les parents de lavenir neuromoteur des nouveau-ns risqu. In; Motricit crbrale Radaptation Neurologie du dveloppement. Ed. Masson. Paris. P.97-103 7. Larroque B, Ancel PY, Marret S, Marchand L, Andr M, Arnaud C,Pierrot V, Ros JC, Messer J, Thiriez G, Burguet A, Picaud JC, Brart G, Kaminski M. 2008. Epipage study group.Neurodevelopmental disabilities and special care of 5-year- old children born before 33 weeks of gestation (the Epipage study) : a longitudinal cohort study. Lancet; 371: 813-20. 8. Leroy - Malherbe V. 2004. Enfant premature et trouble de la motricit. In: Motricit. 19me sminaire Guigoz. Groupe dtudes en Nonatologie- Ile de France. Ed. Laboratoires Guigoz, Deauville, 7-9 nov: 63-92.

9. Le Metayer M. 1993. Le dveloppement de lenfant. In: Reducation crbro-motrice du jeune enfant. Education thrapeutique, kinsitherapie pdiatrique, Fausser C et VinonC. Ed. Masson Paris, p. 15-44. 10. Pinol B, Lacan C, Cambonie G. 2011. valuation prcoce sensorielle et motrice du nouveau-n vulnerable. Ed. Sauramps medical. 11. Ros JC , Bureau-Rouger V.,Beucher A., Branger B., Bouderlique C., Flurin V., Perrier I., Nguyen S., Gosselin J. 2007. Rseau de suivi des nouveau-ns risque de developer un handicap. Lexprience du rseau de suivi regional grandir ensemble en Pays de la Loire. Arch Pediatr; 14 suppl 1: 565-70. 12. Vohr Br., Wright LL., Poole WK., Mc Donald SA. 2005. neurodevelopmental outcomes of extremely low birth weight infants , 32 weeks gestation between 1993 and 1998.Pediatrics; 116: 636-43.

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