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June 9 2012 7 09 /06 /June /2012 22:00


The Asymmetrical tonic neck reflex (ATNR) is a primitive reflex that is found in new born babies and normally remains until around 6 months. It emerges in utero at around 18 weeks after conception and is usually identified and seen within the first 3 months after birth. The reflex is initiated when the head is turned to the left or the right whilst the baby lies on its back. The turning of the head causes the arm and the leg on one side to extend, whilst the limbs on the opposite side flex. If the head turns to the right, the right arm and leg will automatically extend whilst the left arm and leg both flex. It is often called the "fencing" reflex due to this pattern.      


The purpose of the ATNR is to provide stimulation for developing muscle tone and the vestibular system whilst in the womb before birth. It also assist with the birthing process by inhibiting limb movement and slowing it down so that the baby uses a "corkscrew" movement through the birth passage. ATNR helps with eye-hand co-ordination and serves as a precursor to this skill. A retained ATNR can have a significant impact on a child's development and it is often thought to have a major effect on the child's physical, cognitive, social and emotional progress, thus affecting their ability to function well in school. The retained reflex will continue to influence limb movement every time the head is turned and will have physical influences that impact on all other areas.



The ATNR will interfere with a baby's ability to centralise and reach things within the mid line position of their body. Once this reflex is integrated (around 6 months) the baby begins to reach and have functional ability within the mid line of their body. A strongly retained ATNR will affect this ability so that the baby finds it difficult for hands, feet and eyes to cross the mid line. Visual tracking and eye pursuit of an object becomes difficult and this later results in difficulty with reading as the child can not easily make the rapid forwards and backwards eye movements (saccades) that are essential for reading. Writing will also be difficult due to this as well as due to the reflex causing the hand to involuntarily extend as the head is turned towards the hand. The child will find it difficult to maintain a pen grip and may compensate with a lot of pressure in a tight grip, causing cramps and making their writing messy and illegible. The child may also find it difficult to copy written work as their eyes will follow their hand and not the text.




The retained ATNR prevents a baby from developing certain physical cross pattern movements such as rolling over, crawling and later marching using alternative leg and arm. As they grow older the child may have atypical movement patterns and may draw circles backwards, clap downwards, use one hand more than the other whilst clapping, or may be very single handed in most activities. A strongly retained reflex in the legs can also affect balance as the child looks from left to right. Walking, running and other physical activities can be uncoordinated and the child could have difficulty with symmetrical movements of the hands and feet.  A strongly retained ATNR may eventually cause physical problems in the child's bone development. It may affect joints as well as the skeletal structure. It is often seen in children with scoliosis (curving of the spine).





When assessing and identifying a child with a retained ATNR, therapists will look for key features that indicate the child has retained the reflex. It may be mild and difficult to detect, or strong and obvious. If the child displays three or more of the following symptoms, further investigations should be conducted:

  • Difficulty with visual tracking and crossing the mid-line.
  • Difficulty with reading and following a line of text. Easily losing their place when reading. Difficulty reading small print.
  • Listening skills and attention skills are difficult to develop.   
  • Difficulty with binocular vision so that images are blurred. Double vision as two eyes can't work together well.
  • Poor handwriting and difficulty copying written script. Tight pencil grip.
  • Difficulty with spellings.
  • Poor eye-hand coordination.
  • Difficulty with bilateral coordination.
  • Poor sense of direction.
  • Difficulty catching and throwing balls. Often using one hand to throw.  
  • Poor gross motor coordination and balance.
  • Difficulty with swimming, especially breast stroke.
  • The child finds it hard to tell their left from right.
  • Poor short term memory and difficulty following verbal instructions.
  • Impulsive and emotionally immature for their age.


The retained ATNR is often thought to be associated with dyslexia and attention deficit disorder. If a child is having marked difficulties with the above areas they would need an assessment to determine if the ATNR reflex has been retained. Occupational therapists use a variety of methods to test for the reflex. This ranges from a quantitative rating scale that indicates the degree of integration of the ATNR in normal first and third grade children for comparison; to Sensory Integration clinical observation assessments as well as observations of the child performing daily functional activities.


The ATNR can be integrated with therapy in which a series of exercises, specific games and activities are used. The activities involve movements which replicate the early reflex movements and therefore lay down the neural pathways that will enable the child to overcome the retained reflex. With young babies over 7 months a simple exercise would be to work with them on their stomach (prone position) reaching for toys in front and to either side of them. With young children, games can be used that involve e.g. crawling with their head turned to one side (tuck a bean bag or small soft ball under the chin between the shoulder). This can be done as a race. Simple exercises can be done with older children such as one handed wall push ups (standing sideways to the wall) with one hand on the wall and the other hand on the hip as the child faces away from the wall.



 Once the child has integrated the ATNR improvements in classroom performance will be noticed providing there are no further underlying conditions or difficulties. Progress is different for each child and the activities should be done under the supervision of your therapist to ensure success and desired results.
















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September 30 2011 6 30 /09 /September /2011 09:00

imagesCAZVIZ47Babies learn to move around and investigate their environment as part of their natural developmental process. They begin by rolling, shuffling, sitting and finding different positions to reach objects or to move towards an object. Natural curiosity and a need to explore will result in more effective ways of getting around. At about 6 to 8 months a baby will learn to balance on their hands and knees and will gradually learn how to move forwards and backwards by pushing off with their hands and knees. Crawling usually happens at around 9 or 10 months, but some babies never crawl and find other methods to move around such as bottom shuffling or sliding on their tummies.




The Importance of Crawling

As a baby crawls he is learning to move around the environment on his own and therefore has a sense of independence. The baby can decide where he goes and he will start to develop decision making skills based on movement which include motor planning. His muscles are being strengthened in preparation for walking and he is using the limbs on either side of the body to develop bilateral co-ordination.


Crawling is seen as an important developmental milestone in terms of brain development. Some links have been made with the lack of crawling and dyslexia, poor co-ordination, ADHD and other similar problems in healthy children. There is, however, no proven evidence to support the link between not crawling and these conditions. Children with physical issues that prevent crawling have pre existing problems which cause them not to crawl. It is not the lack of crawling that causes these problems. Retained infantile reflexes such as the symmetric tonic neck reflex can cause many problems including learning difficulties. The underlying problem causes the lack of crawling and not the other way round.




Benefits of Crawling

Crawling has many benefits as it is part of the natural developmental progress to standing, walking and running. A baby needs to learn to lift its body off the floor whilst on all fours and maintain that position. This helps to align the spine and develop the muscles of the back, hips and shoulder girdle in preparation for standing. 


Crawling is beneficial for many reasons which include social, emotional, motor, cognitive, sensory and personal (well being) factors. While crawling a baby will be able to connect with his parents in new ways. He can check to see where they are by turning around and looking back whilst crawling away. This develops a stronger 'self' identity and increases his independence. The baby will also be able to discover that things exist far away from him. He gains experience necessary to calibrate how far away an object really is, developing visual skills as well as perception e.g. the more crawling it takes to reach an object, the further away it is, and vice versa. He also learns how to navigate his environment and will learn from the environment as he notices and experiences new things.


Crawling helps to develop balance, strengthen muscle tone and develop eye-hand co-ordination. This is necessary for future reading writing and physical activities. Bilateral integration is improved through crawling as both hands, legs, eyes and ears are required to work in synchronisation, increasing left and right brain co-ordination. The crawling movement is repetitive and this stimulates brain activity to develop cognitive processes such as concentration, memory, comprehension and attention. 


Crawing smile  


Sensory Processing

Crawling allows for the integration of sensory information. This  allows the baby to have a complete picture of his environment. He learns spatial concepts and develops the visual and auditory systems. As the baby crawls he will use both ears simultaneously for reception to develop binaural hearing. Both eyes are also used to begin to develop binocular vision.


Crawling stimulates the inner ear of the vestibular system whilst the baby moves forwards (or backwards) and moves his head. This will help improve balance. Crawling will also give the baby sensory stimulation through his hands and knees as he weight bears through them. This is essential for gross and fine muscle development. He will also receive different tactile sensations as he crawls over different textured surfaces.


Not all movement 'styles' or variations on crawling give the same developmental benefits as the 'traditional' crawling movement pattern. Normal crawling uses both arms and legs alternatively to move. The movement is forward, however, backward movement is often seen when babies are just learning to crawl and that is normal.




Helping Babies to Crawl

Babies develop skills differently and some learn quicker than others. If a baby does not show interest in crawling or moving around (creeping, scooting, shuffling etc.), then they should be encouraged and enticed by placing objects out of their reach or by calling them to you. Most babies who have had plenty of Tummy Time will find crawling to be a natural progression because they are used to being on their tummy and have pushed up with their arms may times in preparation for movement. There may be underlying physical or neurological reasons why a baby will not be able to crawl, or it may simply be due to environmental or motivational factors.




There are many toys and stimulating object on the market to encourage our little ones to crawl. there are also ways to help and assist children with special needs to move about appropriately at that developmental stage. The baby may just need a small amount of encouragement by doing something different like getting down on the floor with him, laying him on his stomach and assuming the same position in front of him where he can see you. This may provide enough encouragement and incentive for your baby to want to move towards you. If your baby is not crawling by 12 months and has not moved on to standing or walking, then professional advice should be sought.









Useful Links:









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March 23 2011 4 23 /03 /March /2011 22:19



What is it?

 Erb’s Palsy (also known as Brachial Plexus Paralysis) is a condition which is mainly due to birth trauma. It is a paralysis of the arm that can affect 1 or all 5 of the primary nerves that supply the movement and feeling to an arm (specifically the upper trunk C5-C6 is severed to cause the palsy, but not exclusively). These nerves form part of the brachial plexus. They come out of the spinal chord between the bones of the neck (the vertebrae), comprising the ventral rami of spinal nerves C5, C6, C7, C8 and T1. The brachial plexus are the major nerves of the arm and run from the neck, passing under the collar bone to the level of the armpit.

Each baby’s injury is individual and the paralysis can be partial or complete. The damage to each nerve can range from bruising to tearing, so prognosis depends on the extent of the damage. Some cases resolve on their own over a period of months, whilst others require specialist therapy or even surgery. In all cases, however, early intervention is crucial so that the full extent of the damage can be ascertained and treatment begun. Treatment in the first year of life can have a significant impact on recovery.


Nerves are chord like structures of tissue from a collection of nerve fibres. One nerve may contain thousands of fibres (like a telephone cable). These fibres in the arm carry electrical messages from the brain to the muscle so that the muscle can work and move the arm. When a nerve is damaged the muscle that moves the arm may be weakened as the message is not getting to the muscle. Damaged nerve fibres that are outside the spinal chord can repair themselves; however, if an entire nerve is damaged or broken it can not grow back to the muscle.


Main Cause

The most common cause of Erb’s Palsy is an abnormal of difficult childbirth or labour. It can happen if there is excessive pulling on the shoulders during a head first delivery. It can also be the result of the baby’s head and neck being pulled towards the side at the same time as the shoulders pass through the birth canal. The injury can also occur in a breech delivery where there is pressure on the raised arm. Similar injuries can occur at a later age following a traumatic fall onto the side of the head and shoulder, where the nerves and plexus are violently stretched.




The signs of Erb’s Palsy include loss of sensation in the arm as well as paralysis and atrophy of the deltoid, biceps, and brachialis muscles. This results in a characteristic position of the arm where it hangs by the side and is rotated medially; the forearm is extended and pronated. The child can not raise the arm from the side and the elbow can not be flexed (bent). The forearm can not be supinated (rotated and turned upwards with palm facing up). The classical physical position is called a “waiter’s tip” (turning backwards).

When all the nerves are affected and the entire arm and hand is limp, there may be an associated Horners syndrome. This is when the child’s eye lid droops and the pupil in the eye may be smaller. There may be an associated Torticollis too (the baby faces away from the affected arm and is unable to face forward for any length of time). If the injury occurs at birth it may stunt the growth of the arm from the shoulder to the fingertips.


There are many factors that affect how severe the injury is and this, in turn, depends on the number of nerves affected. The paralysis can be partial or complete and the most commonly involved nerves are the suprascapular nerve, musculcutaneous nerve, and the axillary nerve.  Sometimes all the nerves may be affected causing weakness or paralysis of the entire arm or hand. The injury is so individual where by one or all of the muscles can become paralysed. Treatment will, therefore, depend on the specific patient. There are, however, four classifications of Erb’s Palsy that describe the severity of the injury:

 ·         Stretch

 ·         Neuroma

 ·         Rupture

 ·         Avulsion (most severe type)

Stretch- The fibres have only been mildly stretched and the child can recover use of the muscle quite quickly. The more fibres that are stretched or pulled apart, the weaker the muscle will be and the longer it will take to start working properly again.

Neuroma- The nerve is severely damaged, but still remains connected. It may heal, but scar tissue may form at the site of the injury. The scar tissue may stop the electrical messages from the brain getting to the muscle.

Rupture- The nerve is completely pulled apart and can not repair itself. The muscles it controls will remain paralysed. It is sometimes possible to have surgery that will restore some nerve function; however, the child is likely to be left with some residual weakness in the arm.

Avulsion- In rare cases the nerve is torn away from the spinal column. Neonatal/paediatric neurosurgery is often required.



For the babies that do not fully recover on their own (usually evident within 3 to 4 months), specialist intervention is required.  Range of movement is usually recovered within a year, but individuals that have not healed after this point will rarely gain full function in their arm, but may continue to improve. They may also be prone to developing arthritis.

Occupational Therapy and Physiotherapy (combined with Hydrotherapy) are the main forms of treatment besides surgery. Once the child has had surgery they will need OT and PT to support the surgical results.

Most of the initial Occupational Therapy treatment will involve the parents. They usually have home programmes and their therapist shows them how to carry out the exercises and activities. These have to be done several times a day with at least 10 repetitions of each motion. The programme becomes part of baby’s life and daily routine.



The programme includes gentle range of movement exercises for the baby in a prone lying position. The aim is to increase joint flexibility and muscle tone as well as sensory awareness with tactile stimulation using various textured materials. The extremity of the limb needs vibration and massage to increase its sensory awareness in the overall body scheme.

Joint compression/weight bearing throughout involved extremity will increase the proprioceptive input/muscle contraction.

The active use of the arm in purposeful activities that are developmentally appropriate will encourage range of movement and increase strength and co-ordination. These movements should be graded beginning in gravity eliminated and then advancing to against gravity.

Bilateral motor planning activities should always be included.

Sometimes splinting may be necessary e.g. to hold the arm in supination and external rotation. The Occupational Therapist will advise on suitable and necessary splinting methods.

Usually the last movements to return are:

·         Full shoulder flexion/abduction using deltoid musculature

·         Supination (children do not actively and spontaneously do this until 11 months of age)

·         External rotation

·         Full elbow extension using triceps


Shoulder Strengthening


In eighty percent of these cases, a baby born with Erb’s palsy will recover without the need for surgical Erb’s palsy treatment. In other cases children can benefit from surgical Erb’s palsy treatment and other rehabilitative techniques. Research has shown that children between the ages of five and twelve months benefit most from surgical Erb’s palsy treatment. Surgical Erb’s palsy treatment is often less effective after one year of life. Younger children tend also to recover more quickly from surgery to repair Erb’s palsy.


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December 6 2010 2 06 /12 /December /2010 12:40

Tummy Time!



There is an abundance of information on the importance of Tummy Time for babies and the developmental benefits it brings. Due to this wealth of information and the escalated health campaigns, mothers are becoming more aware of the need to place their babies on their tummies daily. Before the Back to Sleep campaign in the early 90s (to prevent Sudden Infant Death Syndrome SIDS)


 babies were naturally placed on their tummies to sleep and therefore had ample Tummy Time.  They became accustomed to this position from birth and had the opportunity to learn to lift their head and prop on their arms while on their tummy.


Importance of Tummy Time

When you place your baby on their tummy you are enabling them to practise and achieve important developmental mile stones. Tummy time helps motor development by strengthening their back muscles and allowing them to gain head and trunk control. It also helps develop perception, body awareness and sensory motor skills as well as a whole array of Sensory Integration systems that include vision, tactile and proprioception.


The focus in most literature, however, is on the importance to the motor development and the prevention of motor delay. Motor control develops in a cephalocaudal fashion. This means that a baby will gain head control first and then shoulder control, then the abdomen, and so on down to their feet. If babies don’t get the strengthening of the back and neck muscles that they need, it can lead to or exacerbate an early motor delay.


Early motor delays are increasingly being diagnosed with and estimated one in 40 babies diagnosed and 400,000 babies a year at risk (Smith, D. 2010).  “Early motor delay” was used as a description within a wide range and variety of conditions from low muscle tone to cerebral palsy. Some of these early motor delays are present from birth, whilst others develop or worsen because the baby does not get enough tummy time. The positive thing is that most of the early motor delays are not so serious and with Occupational Therapy and Physiotherapy that involves a programme of tummy time, most children can catch up quickly.


When To Start Tummy Time.

Tummy Time can and should be started with a healthy new born baby. This will make it easier for the baby to accept and get used to being placed in this position. It is often not so practical as with a new born baby the main concerns are with feeding, sleeping, changing and bonding. Tummy time would therefore need to be centred on soothing and holding and would be for short periods of time (around a couple of minutes several times a day). After 3 weeks of age the baby will start to recognise faces and sounds and this makes Tummy time much easier as the length on her tummy can be extended with fun objects and faces to look at. The aim is to get around an hour total within a day by the end of three months.


Difficulties with Tummy Time.

Most babies will initially find being on their tummies uncomfortable or unusual, but they soon get used to it and eventually enjoy it as a natural play position. There are, however, a small minority of babies that just don’t seem to tolerate being on their tummies despite their mother following all the advice on “short bursts” and “making baby comfortable”. These tend to be babies that have colic, severe reflux, sensory processing difficulties as well as other dysfunctions. They are generally restless babies and will not sleep well or fall into a routine. Many of these babies will want to be held most of the time and have difficulty settling.


It is important to find a Tummy Time strategy that works for these babies and this will usually incorporate some form of Sensory Integration (SI) input. The input does largely depend on the difficulty or dysfunction that the baby has and this would need to be assessed by a Paediatric Occupational Therapist for an individual strategy. In more general terms, however, I have found that many Tummy Time difficulties can be overcome by using SI techniques that are calming and by giving vestibular input as well as propriocetive input. This basically means that gentle rocking/swaying and holding baby very close will calm them down a notch (this is also considering that they have been fed, changed and are not sleepy). For new born babies, carrying them extended along your arm, with your arm between their legs is an ideal way to very gently swing/rock them whilst holding them close to your body. They can also gradually be introduced to the Tummy Time position by laying them upright on your chest and then gradually inclining back a little each day until flat on the floor. Music is a very good distraction so it would be advisable to play some calming music in the background.


At the beginning of 4 months the baby should be pushing up on its forearms and lifting and holding its head up. Cause for concern is when the baby has some difficulty lifting its head, has stiff legs with little or no movement, pushes back with its head or turns its head to one side only.






There are some very good informative video clips on tummy time and its importance at the following link:  www.pathwaysawareness.org/top/pathways-video-tummy-time-english-and-espanol1/ 




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