Respiration & Trunk control The Great Connection. are part of a complex combination of interactive systems. Muscles of respiration are part of the musculature of dynamic postural control. First 3 Years of Life: Respiratory structures are still developing. Lung tissue is still changing. Increased movement = increased changes in lung tissue. Rib cage reflects the forces that have been place on it. Brief Review of Normal Development of the Rib Cage Rib cage develops in 3 dimensions: Anterior horizontal sagittal plane. Vertical anterior / posterior sagittal plane. Lateral / Diagonal frontal & transverse plane. Newborn High, horizontal ribs with narrowing of the shoulder girdles & upper rib area the shoulder girdles & ribs are working together. Respiration: nose breathing Belly breathing: anterior rib cage & sternum collapse when crying & upset. Direct relationship between breathing/ sound production / body movement. 3 5 months Develops antigravity extension & flexion through activity in prone & supine. Increased range, mobility ++ Increased thoracic & lumbar extension. Rib cage: Swimming movements: upper rib cage expansion Pectorals, Serratus Anterior, Increased mobiiity of ribs on sternum, ribs on scapulae & vertebrae. Increased thoracic extension / scapular stability = increased developement of active upper trunk & upper extremity flexors. Abdominals are pushed into surface = increased diaphragmatic activity. Lateral weight shift beginning of lengthening of intercostals & opening up of rib cage. Respiration: belly breathing at rest & during quiet breathing: sustained & rhythmical. With crying & more active movements -increased flaring of lower ribs with more active movements in prone & supine. May still see some retraction of the ribs. Sound production: greater variation in loudness, duration, pitch, & tension. Begins to differentiating cry with different states. Begins cooing, nasal vowel sounds with body movement. 1
6 months Body shape: more length, more contouring = more prominent rib cage contour. Prone: more extension trunk elongation & lower extremity extension on 1 side with elongation on the opposite side. Supine: abdominals more active. Rolling. Uses side lying for play. Rib cage: mobility continues to increase - rib angles are now beginning to rotate downwards connecting the lower ribs pelvis through the intercostals & abdominals. Respiration: Deeper inhalation, belly breathing with anterior rib cage flatter. Sound production: Different sounds & cries for different situations: pain, anger, fussing, hunger, delight. Coos with consonant sounds, longer duration & nasality. Begins babbling. 7 9 months. More upright: sitting, 4 point, standing at support. Transitions: sitt to 4 point, rolling, etc. Variety of base of support increased allowing for greater mobility with active stability. Rib cage: still changing: increased mobility - more lateral & rotatory movements increased active control. Active obliques on active hips & trunk with alignment. Respiration Belly breathing with greater expansion on inhalation less rib flaring. Beginning of lateral /anterior expansion of rib cage during inhalation when posturally active & stable. Better coordination of movement with sound production, feeding, swallowing. Also beginning to separate body movement from sound production = better respiratory base. Sound production: Vocalizes pleasure & displeasure. Babbles longer chains of sound sequences, with variation in loudness, pitch, intonation. Begins producing more sounds: consonant vowel / consonant combinations, including lips, tongue. 10 12 months Efficient postural alignment with an S postural curve. Initiates & controls weight shifts from the hips & lower trunk. Sits in a variety of ways, climbs, standing to play, cruises. Rib cage: end range of rib mobility as the movements expand to Extension with rotation in all directions Flexion with rotation More integration of mobility/ activity, which has a direct influence on range of functional activities. 2
Respiration: belly breathing with minimal rib flaring. Abdominal- thoracic breathing pattern developing: thoracic expansion occurs during crying & activities when abdominals are more active. Sound production: sounds produced separate from body movements now. Wide variation of vowel combinations, consonants / vowels, etc. First real words. Factors influencing rib cage & respiratory musculature & activity. Mobility Within the skeletal framework of the rib cage Oral motor with facial, & pharyngeal Head & cervical spine Shoulder girdle & upper extremity Lumbar spine & hips Lower ribs Elongation & activation of all respiratory musculature: Within & directly attached to the rib cage skeletal framework. Head & cervical spine Oral motor with facial & pharyngeal Shoulder girdles & upper extremity Diaphragm Abdominals as well as lumbar spine & hips Oral motor & pharyngeal Diagnosis: L1CAM - X-linked aqueductal stenosis - congenital hydrocephalus with developmental delays (including congenital thumb adduction), motor abnormalities, central & obstructive apnea. Functional limitations 1. Unable to sustain independent sitting, prone for feeding, play, interaction / exploration of the environment at home & at the day care. 2. Difficulty with movement on floor for exploration of the environment: rolling, moving in & out of sitting, pulling to stand. 3. Poor control & variety of respiration for access to movement respiration / phonation & feeding. Limited respiratory excursion affects endurance, adaptability to movement & also trunk control for sustained active support against gravity. Impairments Hypotonia resulting in weakness of trunk, head & neck, shoulders & upper extremities & lower extremities. Poor sustained control against gravity in all positions with poor base of support & inadequate postural alignment. 3
Weak grasp with very limited weak reach. Limited range & variety of movements in any position. Respiratory impairments. Inadequate respiratory excursion for functional inspiration / expiration. Limited mobility of ribs on sternum & spine. Poor activation of muscles supporting breathing: head & neck, spinal extension (thoracic & lumbar) & abdominals. Lack of space within chest wall for adequate functional breath support: decrease mobility & activity of rib cage & diaphragm to move within the trunk. Secondary Impairments Risk of dislocation of shoulders & hips. Further contracture of both thumbs. Environment & psychosocial barriers Dependent for all needs that will affect daily care & interaction with the environment at home & day care. Difficulty with communicating needs, discomfort, etc Objective measures: Measurement of respiratory excursion in supine & supported sitting. Observation & timing of ability to sit & play: base of support, alignment with reach & manipulation of toy. Treatment Plan Immediate Teach parents (& others) basic safe handling skills: positioning, picking up, carrying, undressing etc. Awareness of safety for R & themselves. Equipment to support daily needs: postural insert, bath seat, seat for day care / home for short periods, other adjuncts knee extension splints, Nu Stim for thumbs. Functional Goals. R will have sufficient breath support to be able to sit with trunk straight over a well-aligned base of support in front of a low stool in order to reach for a toy with minimal physical help for 3 mins. He will be wearing knee immobilizers. R will be able to maintain sufficient head control with good alignment, good dissociation of head & neck from shoulders while being carried for 3 mins while weight is being shifted in different directions. R will be able to roll actively over his base of support to R or L, from supine to prone while reaching for a toy & lifting his head up. 4
R will be able to reach for actively maintaining shoulder flexion & elbow extension for a toy with thumbs in abduction & hold it for 1 minute in a supported position (supine or sitting) while wearing strapping on thumb. Objectives. Rib cage mobility (i.e., ribs-to-spine, ribs-to-sternum, and ribs-to-ribs) especially horizontal & vertical expansion. Chest wall musculature elongation intercostals, abdominals in sagittal & frontal planes Downward rotation of the ribs. Realignment of the thoracic cage (i.e., rib cage and shoulder girdle complex) downward within the trunk. Activation of the abdominal musculature (e.g., rectus abdominus, internal abdominal obliques, external abdominal obliques) for elongation of the intercostals between the ribs and stabilization of the lower rib cage. Realignment and activation of the head & neck & shoulder girdle on the upper rib cage i.e. a stable base of support. Other Strategies Active weight shifting over base of support from supine. Alignment of hips & lengthening of hip abductors for adequate weight shift. Active head control with neck elongation against gravity during movement into extension, lateral & flexion. Good alignment & support to trunk & pelvis. Adequate respiratory excursion to support active sitting. Active trunk extension with flexion over base of support, hips in line with pelvis. Shoulder stability for active reach. Weight shifting forwards over base of support & return to midline. 5
Equipment & Adjuncts Custom made insert with high chair base. Knee immobilizers. Ingenuity 2 in 1 seat. Nu Stim strapping for thumb alignment. Standing frame. AFOs on order. Notes taken from the following courses: Bibliography Advanced NDT Baby Course (12 days) 2014 Instructors: Kacy Hertz PT., Madonna Nash OT, Rona Alexander SLP. Rib Cage: Focus on the Rib Cage for improvement in Respiration, Phonation, Postural control & Movement. (3 days) 2011 Instructor: Rona Alexander CCC-SLP, PhD. If You Can t Breathe You Can t Function. (2 days) 2013 Instructor: Mary Massery, PT 6