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I. Gross motor development


  1. Role of the neonatal physical therapist

    The role of the physical therapist (PT) in a neonatal intensive care unit (NICU), transitional care unit, or follow-up clinic is to evaluate and treat the sensorimotor function of the developing infant. Physical therapists trained to work in this clinical area are not only considered specialists in the multifaceted aspects of infant development, but are also acute care specialists, with extensive clinical expertise in dealing with critically ill pediatric patients. The purpose of an evaluation by a neonatal PT is to

    • Recognize musculoskeletal impairments.

    • Identify positioning techniques to improve flexion.

    • Determine ways to enhance neurobehavioral organization through adaptations in the infant's environment.

      The physical therapist's goal of promoting an infant's sensorimotor development needs to be addressed as soon as the parent and the infant are stable after birth. Providing positioning and environmental recommendations to the parents and nursing team can be instrumental in preventing posture and movement deviations typically seen in acutely ill infants. A PT is often one of the first team members to educate parents on the specific developmental needs of the “high-risk infant.”

  2. Patient population

    The typical patient population seen by the neonatal PT can be divided in two main categories: preterm and sick term infants. These patients are often termed high-risk infants because, although their early life experiences are very different, they show similar posture and movement deviations that can lead to delays in gross motor development. These deviations include

    • An overall extension bias in both posture and movement (Figure 44-1)

    • Lack of varied and vigorous spontaneous movement, especially flexion against gravity

      These tendencies are the result of the infant's medical diagnoses, as well as a result of prolonged illness/immobility in the NICU.

Figure 44-1

Extension bias of lower extremities. (Image used under license from

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II. Patterns of movement


  1. Normal developmental sequence of gross motor skills

    The fetal environment can strongly influence physiologic development throughout infancy and early childhood. The following is a general guideline for motor milestones typically achieved in the first 6 years of life. Variability within the provided ranges can be expected.

    0 to 2 Months

    • Kicks legs alternately while in supine

    • Bends and straightens arms

    • From right or left side, rolls to supine

    • Turns head cheek to cheek in prone

    • May lift head to ~45? in prone

    • Bears weight through flat feet in supported standing with knees bent

    • Holds head upright in supported sitting for several seconds

    3 to 4 Months

    • Holds head in midline and brings hands to midline/mouth while in supine

    • Smooth (alternating or together) movements in arms and legs

    • Grabs knees by flexing trunk

    • Lifts head/trunk 45? to 90? off the surface in prone with weight on forearms

    • Rolls from prone to supine and may be able to roll supine to prone

    • Holds head steady ...

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