Physical & Occupational Therapy in Pediatrics, 33(1):75–110, 2013C© 2013 by Informa Healthcare USA, Inc.Available online at http://informahealthcare.com/potpDOI: 10.3109/01942638.2012.750870

Physical Therapy Intervention in the NeonatalIntensive Care Unit

Eilish Byrne1 & June Garber2,3

1Neonatal Intensive Care Unit, Lucile Packard Children’s Hospital, Palo Alto, CA, USA,2Neonatal Special Care Nurseries, Emory University Hospital Midtown and Grady

Memorial Hospital, Atlanta, GA, USA, 3Division of Physical Therapy, School ofMedicine, Emory University, Atlanta, GA, USA

ABSTRACT. This article presents the elements of the Intervention section of the In-fant Care Path for Physical Therapy in the Neonatal Intensive Care Unit (NICU). Thetypes of physical therapy interventions presented in this path are evidence-based andthe suggested timing of these interventions is primarily based on practice knowledgefrom expert therapists, with supporting evidence cited. Physical therapy intervention inthe NICU is infant-driven and focuses on providing family-centered care. In this con-text, interventions to facilitate a calm behavioral state and motor organization in theinfant, address positioning and handling of the infant, and provide movement therapyare presented.

KEYWORDS. Physical Therapy, Neonatal, Intervention, Therapy, NICU

This article describes the physical therapy interventions included in the Infant CarePath for Physical Therapy in the Neonatal Intensive Care Unit (NICU) (Figure 1,Campbell, 2013). The types of physical therapy interventions included in the In-fant Care Path for Physical Therapy in the NICU are evidence-based. The sug-gested timing of these interventions was primarily driven by practice knowledge,with evidence regarding timing cited as available. The suggested time line for inter-ventions was developed with input from five expert therapists across the country,allowing for regional representation regarding neonatal physical therapy practice.For a more thorough discussion of the development and use of care paths in gen-eral, please refer to the article entitled “Use of a Care Path” (Campbell, 2013). Thisarticle will present interventions for facilitating a calm state and motor organiza-tion, positioning and handling of the infant, and providing movement therapy. Thecontext for providing these interventions includes a developmentally appropriate,family-centered approach to care where environmental challenges are considered.

Address correspondence to: Eilish Byrne, Neonatal Intensive Care Unit, Lucile Packard Children’s Hospital,Stanford University, 725 Welch Road, Rehabilitation Services – 3rd Floor, Palo Alto, California 94304, USA(E-mail: ebyrne@lpch.org).

(Received 15 September 2011; revised 27 August 2012; accepted 21 September 2012)

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FIGURE 1. Infant Care Path for Physical Therapy in the Neonatal Intensive Care Unit.Source: Campbell (2013).

This article begins with a discussion regarding the contexts in which the interven-tions occur.

INFANT-DRIVEN, FAMILY-CENTERED APPROACH

Providing developmentally appropriate care to infants and families in the NICUrequires a dynamic, continuous approach to intervention. Relationship-based (in-fant driven), family-centered caregiving is a critical element of developmental care

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Physical Therapy Intervention In Neonatal Intensive Care Unit 77

FIGURE 1. (Continued)

(Bowden, Greenberg, & Donaldson, 2000; Gale & Franck, 1998). Physical thera-pists in the NICU promote developmental relationship-based care of the infant.To accomplish this, the physical therapist provides interventions to facilitate infantdevelopment while collaborating with the parents to support their needs to engagewith and parent their infant.

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Providing and modeling relationship-based care of the infant requires that thephysical therapist not only recognize, but also respond appropriately, to infant be-havioral cues (Als et al., 2003). It is through responding appropriately to infant cuesduring care that development of behaviorally beneficial neuronal pathways is sup-ported in the infant through modulation of the infant’s neurobehavior (Als et al.,2004). A useful model of infant behavior to guide physical therapy care in the NICUis the synactive model of infant development (Als, 1982) in which interdependentbehavioral dimensions are organized as subsystems and affect infant neurobehav-ior. These subsystems include the autonomic system, the motor system, the stateorganizational system, the attentional-interactive system, and the self-regulatorysystem. In using this model, the physical therapist observes whether the five sub-systems are working well together to provide the infant with physiologic stabilityand the ability to engage in social interactions. If the physical therapist recognizesthat the infant is communicating signs of stress, the appropriate response is to iden-tify the stressor and eliminate it if possible.

The Newborn Individualized Developmental Care and Assessment Program(Als, 1982) is a developmental care framework that can be used in the NICU set-ting to help guide caregiver–infant interactions. For instance, the physical therapistshould schedule sessions at a time that is most appropriate for the infant and fam-ily, as well as in conjunction with the bedside nurse’s schedule for routine care andfeeding. Typically, services are delivered prior to a scheduled feeding. Respectingan infant’s right to sleep (and need for recovery from handling) is an importantaspect of providing developmentally focused care. Deep sleep is important for thedevelopment of the neurosensory system and the maturing brain (McGrath, 2007).Some research findings have been supportive of this model of health care delivery.In a study examining outcomes of infants born preterm receiving an individualizeddevelopmental care and assessment program, Peters et al. (2009) found significantlyimproved short- and long-term function, reduced length of stay, reduced incidenceof chronic lung disease (CLD), and decreased mental delays at 18 months correctedage (CA).

There are many factors in the NICU environment that challenge not only theneurodevelopment of the infant but also the development of the parent–infant re-lationship. In the NICU, the infant is exposed to fluctuations in noise levels, temper-ature, light, and schedules of evaluation and care. The infant may endure noxiousstimuli, painful procedures, pharmacologic agents, and too much handling at times.Risk for infection can be high, threatening the health of the infant. It is under thesecircumstances, too, that family bonding can be threatened. During the crisis of hav-ing an infant hospitalized in the NICU, parents may experience feelings of anxiety,helplessness, loss of control, fear, uncertainty, and worry (Miles & Holditch-Davis,1997). These feelings can impact the parent–infant interaction.

A physical therapist provides relationship-based care to the family by fosteringthe parent–infant relationship. One model for doing this is the hope-empowermentmodel (Sweeney & Swanson, 2001) by which the physical therapist builds a ther-apeutic partnership through collaboration with the parent to assist with copingand foster empowerment. In addition to addressing the physical therapy needs ofthe infant, physical therapists have a unique opportunity to collaborate with par-ents through instruction and guidance regarding infant handling and positioning,

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Physical Therapy Intervention In Neonatal Intensive Care Unit 79

appropriate developmental activities (e.g., tummy time for play, reaching activi-ties), and recognition of infant cues and behavior. Instructing parents on how tosafely handle and position their young infants with skill and confidence is a role ofthe physical therapist in the NICU (Sweeney, Heriza, & Blanchard, 2009). Learningand practicing these skills with a physical therapist may increase a parent’s abilityto participate in infant care, and proponents of family-centered care advocate thatappropriate parental involvement will benefit the current and future health of theinfant (Gale & Franck, 1998).

Physical therapists provide family-centered care by understanding how comfort-able the parents are regarding participation in their infant’s care. A model to assessthis defines four levels of participation (Karen I. Wayman, personal communica-tion, October 2010). Level 1 is a medical approach in which information is providedto the family. Level 2 is a family support approach in which the family may be of-fered individual or group support for coping and decision making. Level 3 is familyinvolvement and partnership in care, and Level 4 is family efficacy. Achieving familyefficacy implies that there is a shared decision-making process in the care of the in-fant. Other components of the therapist–parent relationship to address when deliv-ering family-centered care include respect, collaboration, and support (Hutchfield,1999). For a more detailed discussion of family-centered care and the parent–infantand parent–therapist relationships, please see the article entitled “Family Supportand Education” (Goldstein, 2013).

ENVIRONMENTAL CONSIDERATIONS

The environment of the NICU is not inherently conducive to neonatal growthand development. In fact, excessive environmental stimuli experienced by thepreterm neonate may contribute to developmental concerns that emerge at schoolage (Perlman, 2001). Primary environmental considerations include facilitatingneonatal temperature regulation, modifying environmental lighting, and limitingnoise levels. In most nurseries, neonatal temperature regulation is maintainedthrough the use of an incubator (isolette). Temperature regulation contributes toneonatal physiologic stability and energy conservation. To promote temperaturestability, the incubator thermostat is set to provide the heat needed to help theneonate maintain a minimum temperature of 36.5◦C. When providing physicaltherapy in the NICU, it is important to know that the infant’s temperature is withinappropriate limits prior to removing the infant from the incubator or removinginfant clothing and to assess the effects of handling on infant thermal stability.

Lighting in a NICU is bright compared to the darkness of the intrauterine envi-ronment; the infant rarely experiences total darkness. In fact, the infant will likelyexperience exceptionally bright overhead lights during a variety of medical proce-dures. Although bright lights may be needed for certain medical procedures, theinfant born preterm is unable to independently modulate this experience. The useof cycled lighting in a NICU to facilitate the development of the neonatal circadianclock (Rivkees, Mayes, Jacobs, & Gross, 2004) and to promote weight gain for lowbirth weight infants (Jung, 2005) has been advocated, although research is not con-clusive. When removing the infant from an isolette for developmental stimulation,the physical therapist should be careful to keep the infant comfortable and, when

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possible, the environment should be modified to facilitate infant success at a par-ticular developmental task (e.g., dim the lights when facilitating visual interaction).

Modulating the noise in a NICU is important for promoting optimal neonataldevelopment. High noise levels may contribute to neonatal physiologic stress. Stim-ulation from alarms and other external noises can produce neonatal autonomicresponses, compromising physiologic stability (Bremmer, Byers, & Kiehl, 2003).Short-term physiologic responses to elevated noise levels may include changes inheart and respiratory rates (Wharrad & Davis, 1997). These short-term changes mayutilize more energy, limiting the capacity for growth and healing (Brown, 2009). Inaddition to the short-term effects of elevated noise, some researchers express con-cern that prolonged exposure to uninterrupted noise in the NICU may contributeto long-term hearing deficits (Brown, 2009; Levy, Woolston, & Browne, 2003).

Some ways to curb unnecessary noise in a NICU include instituting “quiet times,”closing incubator portals quietly, avoiding tapping on incubators, lowering yourspeaking voice and limiting bedside conversation, eliminating unnecessary over-head paging, silencing alarms when able to, and installing sound-absorbing flooringand fixtures or sound-activated signaling systems to indicate the need to reducesound levels. For the physical therapist, targeting unit “quiet times” to work withthe neonate outside of the incubator may foster neonatal self-regulation.

FACILITATE CALM STATE AND MOTOR ORGANIZATION

The first item addressed in the Intervention section of the Infant Care Path forPhysical Therapy in the NICU (Campbell, 2013) is behavioral state regulation andthe interventions to facilitate a calm state and motor organization, including non-nutritive sucking (NNS), containment, and positioning (including hydrotherapyand “skin-to-skin care”; SSC) (Figure 2). Noxious sensory inputs that an infant bornpreterm experiences in the NICU negatively affect the neuronal organization thatnormally occurs in the last trimester of pregnancy (Als et al., 2004). Noise, brightlighting, and touch can cause physiologic instability and stress and adversely affectdevelopment of the preterm infant (Als et al., 1994; Anand & Scalzo, 2000). Forthe infant born preterm, physiologic stability (e.g., heart rate of 120 to 180 beatsper minute, oxygen saturation approaching 100%, and respiratory rate of 20 to 50breaths per minute) enables quiet alert states and behavioral organization for socialinteraction and functional motor patterns (e.g., hands to midline). It is importantto note that signs of physiologic stability should be evaluated within the context ofthe neonate’s day and individual medical status. Techniques that help the neonateto maintain physiologic stability decrease attention difficulties in infancy (Buehler,Als, Duffy, McAnulty, & Liederman, 1995). Based on documentation of an infant’scompetencies and needs, a variety of techniques can be used to help an infant finda calm, quiet, and organized state. These include sucking, contained and supportivetouch, positioning to foster flexion, midline placement of the infant’s extremities,and using slow transitional movements (Als et al., 1994; Buehler et al., 1995).

Non-Nutritive Sucking (NNS)

Non-nutritive sucking includes placement of an appropriately sized pacifier or acaregiver’s gloved finger within the infant’s mouth to elicit at least some degree

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FIGURE 2. Facilitate Calm State and Motor Organization, Intervention section of the InfantCare Path for Physical Therapy in the NICU. Source: Campbell (2013).

of sucking effort, with minimal fluid other than oral secretions to control. As anintervention method for fragile preterm infants, NNS is initially elicited while therelatively alert infant remains in an isolette in prone or sidelying prior to or duringgavage feeding. Within an infant’s tolerance of handling and ability to maintaintemperature stability, NNS can be facilitated while that infant is held by a parentduring a gavage feeding or at the mother’s emptied breast during “kangaroo care”or “SSC” (Kirk, Alder, & King, 2007).

The NNS experience benefits a preterm infant in multiple ways. Infant’s re-sponses to this oral experience reflect their degree of fatigue as well as their neuro-motor maturity. Among infants less than 33–34 weeks postmenstrual age (PMA),NNS consists of short bursts of licking and usually leads to restful sleep periods.Among more mature preterm infants, NNS is a more complex motor pattern thatnot only helps them calm to sleep when tired but also helps them achieve periodsof quiet alertness. For parents providing NNS, these positive responses from theirinfants contribute significantly to early relationship building and their sense of com-petence as parents. In preparation for the demands of oral feeding, NNS experiencecan improve the strength and control of oral musculature as well as improve the in-fant’s rooting or oral orientation responses (Boiron, Da Nobrega, Roux, Henrot, &Saliba, 2007). These topics are discussed in more detail in the article entitled “OralMotor Function and Feeding Intervention” (Garber, 2013).

Containment

Containment and touch also facilitate self-regulation in the neonate. When appliedby caregivers, facilitated tucking (where the infant is held in a sidelying fetal posi-tion by the parent) was equal to or better than other pain management techniquesafter uncomfortable procedures such as heel stick or pharyngeal suctioning (Axelin,Salantera, Kirjavainen, & Lehtonen, 2009). Contained touch in the NICU typicallyinvolves placing a firm (not too soft, not too hard) hand on the neonate at the topof the head and over the trunk and hip area to flex the hips, thereby “containing”the infant. It is thought to be most effective for infant calming when the caregiver’shands are still and not moving. This technique can be performed as tolerated untilthe infant is calm/relaxed or sleeping.

Swaddling, a containment positioning technique that facilitates flexion, can fos-ter self-regulation of the infant (Neu & Browne, 1997). Swaddling typically involveswrapping a blanket around the infant in such a way as to help the infant maintaingentle flexion of the legs and arms without eliminating small arcs of spontaneousmovement. Swaddling provides support through the infant’s trunk and therefore isa useful positioning technique for breast and bottle feeding, for transitions in and

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out of bed, and for periods of interaction with parents. In a study by Franco et al.(2005), term infants in supine had better sustained sleep and reduced spontaneousawakenings during non-rapid eye movement sleep. In addition, the infants sleptlonger and spent more time in non-rapid eye movement sleep. Swaddling in side-lying and supine was also found to facilitate neuromuscular development (Short,Brooks-Brunn, Reeves, Yeager, & Thorpe, 1996).

Prone and sidelying positions can also provide containment. Among fragile in-fants less than 32 weeks PMA, placing infants in these positions inside an isoletteor on a caregiver’s chest has been shown to facilitate extremity flexion toward themidline, limit uncontrolled flailing extremity movement, and encourage more sta-ble vital signs (Axelin et al., 2009; Heimler, Langlois, Hodel, Nelin, & Sasidharan,1992). In addition, when compared to supine, the prone and left sidelying positionsdecreased the occurrence of reflux from gastroesophageal reflux disease (GERD)in these infants (Corvaglia et al., 2007). Utilizing prone and sidelying positions al-lows infants born preterm to recover from stressful events and calm to sleep bet-ter than in a supine position while being monitored (not appropriate for home).Among more vigorous preterm infants 32–34 weeks PMA, the prone and sidelyingpositions can also extend the duration and improve the quality of emerging inter-active responses.

Sidelying also may facilitate chin tucking for the development of head controland arm and hand movements for hand to mouth/face play and hand to body play,activities that are self-regulatory behaviors (Grenier, Bigsby, Vergara, & Lester,2003). Likewise, placing neonates in the sidelying position may foster motor orga-nization as demonstrated by more coordinated spontaneous midline movements(Nakano et al., 2004). The supine position has been generally seen as less support-ive to the preterm infant’s state regulation and comfort. However, when the goal isto vary the infant’s positioning experience and promote musculoskeletal integrityin supine or when the supine position is preferred medically, using a developmen-tal nest may contribute to better coordinated, midline-oriented movements of theupper and lower extremities (Ferrari et al., 2007).

Skin-to-Skin Care (SSC)

Skin-to-skin care is a positioning technique with particular benefits to the infantand parents. The diapered-only infant is nestled under the parent’s shirt directlyagainst the skin and then a blanket is placed over the infant and parent. Whenimplemented correctly, this position promotes soft flexion of the infant’s arms,legs, trunk, and neck. The immediate benefits for self-regulation may include tem-perature regulation, improved oxygen saturation, and decreased respiratory rate(Fohe, Kropf, & Avenarius, 2000). With support and instruction, parents learn torelax with their infant snuggled in this manner; they learn to provide appropriatelylow levels of stimulation; and they feel valued as providers of this important inter-vention. SSC is associated with decreased length of hospital stay, improved weightgain, and increased frequency of breast feedings at discharge (Bier et al., 1996;Wahlberg, Affonso, & Persson, 1992). In addition, Bier et al. (1996) found that, outof a group of mothers who intended to breast feed their infants, significantly moremothers who performed SCC compared to standard holding (clothed and blan-keted infant) were still breast feeding after one month post-discharge. Regarding

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infant development and maternal health, Feldman, Eidelman, Sirota, and Weller(2002) found that infants who received frequent SSC from their mothers had abetter developmental outcome at six months CA and mothers were less depressed.

Hydrotherapy

Hydrotherapy with a swaddled infant may be a useful adjunct intervention forfacilitating self-regulation. Benefits of hydrotherapy in other patient populations(adults) may include relaxation, decreased pain, improved perceived quality of life(Tinti, Somera, Valente, & Domingos, 2010), and increased cardiorespiratory andrenal functions (Pechter, Maaroos, Mesikepp, Veraksits, & Ots, 2003a; Pechter et al.,2003b). Neonates have demonstrated physiological tolerance of hydrotherapy pro-vided by a physical therapist (Sweeney, 1983). In addition, infants 32–36 weeksPMA who received swaddled hydrotherapy (for details on the swaddled emersionprotocol, please refer to the article) prior to feeding demonstrated improved feed-ing efficiency (Sweeney, 2003).

The Infant Care Path for Physical Therapy in the NICU (Campbell, 2013)indicates that techniques for facilitating a calm state and motor organizationare appropriate throughout the NICU stay, but should be adapted appropri-ately as the infant develops, the infant–parent relationship grows, and dischargeapproaches.

POSITIONING AND HANDLING

The second item addressed in the Intervention section of the Infant Care Path forPhysical Therapy in the NICU (Campbell, 2013) is positioning and handling (Fig-ure 3). Specific topic areas in this section include preserving musculoskeletal in-tegrity, and promoting comfort, respiratory function, skin integrity and containedmovement, splinting, range of motion, and infant alerting. The musculoskeletal sys-tem of infants born preterm is vulnerable to the effects of gravity, poor handling(not properly supporting the infant) and positioning, and the restrictions causedby necessary medical equipment such as boards to hold intravenous lines in place.Physical therapists have an important role in ameliorating some of the potentiallydeleterious effects of these experiences. Because infants born prior to 31 weeksgestational age (GA) have immature muscle fibers and neuromuscular junctions(Lowes, Sveda, Gajdosik, & Gajdosik, 2012) and diminished flexor tone (GrantBeuttler & Shewokis, 2007), developmentally supportive positioning is important.Allen and Capute (1990) described tone development in the infant born pretermto be caudo-cephalad, beginning at about 33–35 weeks PMA in the lower extrem-ities and 35–37 weeks PMA in the upper extremities. The physical therapist needsto position the infant in a manner that facilitates this developmental progression.Sweeney and Gutierrez (2002) suggest that the neck, shoulders, hips, and feet areparticularly vulnerable to the effects of poor positioning and infants born pretermmay experience neck hyperextension, shoulder retraction, external rotation of thehips, and foot eversion when positioned in supine or in prone (without appropriatedevelopmental rolls).

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FIGURE 3. Positioning and Handling, Intervention section of the Infant Care Path forPhysical Therapy in the NICU. Source: Campbell (2013).

Head Shaping and Musculoskeletal Integrity

Varying the position of the infant is important for maintaining musculoskeletalintegrity and avoiding contracture and deformity including acquired torticollis(Sweeney & Gutierrez, 2002; Vaivre-Douret, Ennouri, Jrad, Garrec, & Papiernik,2004), assisting with skull shaping (Najarian, 1999; Neufeld & Birkett, 2000; vanVlimmeren et al., 2008), and providing varied visual stimulation. Varying the in-fant’s position refers to placing the infant in prone, sidelying, supine, and supportedupright regularly throughout the day (ideally) or over the course of a few days.When placing the infant in any of these positions, the physical therapist should takecare to facilitate neutral alignment of joints, support the head and spinal curves, andencourage midline orientation of extremities and opportunities to appropriately vi-sually interact with the environment.

A case report by McManus and Capistran (2008) illustrates a positioning pro-gram implemented in the NICU to promote head shaping of an infant born pretermwith dolichocephaly. Dolichocephaly, which is a head with narrow width and longanterior-posterior cranial distance, is commonly seen in infants born preterm. It isimportant to address in the NICU because it often persists after discharge and mayrequire substantial physical therapy intervention. In this case report, the infant wasplaced on a viscoelastic mattress with a developmental care program in place. Cra-nial molding was measured using the cranial index, a ratio of width to length. Afterimplementing a positioning program to foster midline head position, the cranial in-dex measurements improved to within normal limits. This effect was maintainedat the time of discharge. This case highlights how a physical therapist can preventmusculoskeletal impairment of preterm infants in the NICU.

Promote Comfort and Respiratory Function

Placing infants in certain positions can promote self-regulation and physiologicstability. SSC promotes autonomic regulation (as previously described) and im-proved oxygenation in infants born early (Cleary, Spinner, Gibson, & Greenspan,1997). Likewise, compared to the supine position, the prone position is associatedwith decreased central apnea and periodic breathing (Heimler et al., 1992) and isalso therefore considered to promote stability in neonatal respiration (Levy et al.,

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2006). Levy and colleagues (2006) also noted that prone positioning among healthypreterm infants approaching discharge no longer provided a pulmonary advantageover supine. As reflected in the NICU Care Path at 34 weeks PMA, infants with-out gastroesophageal reflux and/or chronic pulmonary insufficiency can begin thetransition to increased supine sleeping time. The prone position is also consideredto promote general infant comfort, as infants typically “settle” in this position. Inaddition, as previously mentioned, sidelying flexion helps infants calm after painfulprocedures (Axelin et al., 2009).

Promote Skin Integrity and Provide Scar Management

Promoting the skin integrity of the neonate is a role for the physical therapist in theNICU. Healthy skin requires nutrition and oxygen-rich blood. Physical therapistscan intervene in ways that facilitate the flow of blood to areas of skin at risk for com-pression due to body position and gravity. Interventions performed by the physicaltherapist may include facilitated or passive movement of limbs, positioning changesof head/neck, trunk, or limbs, and use of pressure-relieving aides as appropriate.In a study by Marcellus (2004), the bodily area experiencing the greatest amountof pressure in supine, prone, and sidelying was the head (in all three positions),followed closely by the knee in prone and shoulder in sidelying. Special attentionto these areas during developmental positioning is warranted, as the skin of theinfant born preterm is more prone to dryness and injury. In addition, the resultsby Marcellus (2004) emphasize the importance of promoting a variety of well-tolerated positions to be used throughout the day within the context of a devel-opmental program.

Scar management as a component of promoting skin integrity can be a role forthe physical therapist in the NICU, but the evidence supporting the best methodfor this intervention is mixed. Part of what makes evaluating the evidence for scarmanagement difficult is the variety of techniques studied (e.g., silicone gel, siliconegel sheeting, topical medicines, scar massage), the differences in the types of injurystudied (e.g., trauma, burns, medical burns), the differences in the age of the skininjury (recent skin injury or old skin injury), and the variety in patient age fromnewborn to elderly. Due to the heterogeneity of studies, a best method for injurycharacteristics and patient age has not been established.

A Cochrane review to assess the efficacy of using silicone gel sheeting to treatand prevent scarring in other patient populations (O’Brien & Pandit, 2006) foundthat most clinical trials were (1) small, (2) of poor quality, and (3) highly suscep-tible to bias. Since this review, a variety of studies have shown benefits to usinga variety of treatment methods including, silicone gel sheeting (Karagoz, Yuksel,Ulkur, & Evinc, 2009; Sakuraba, Takahashi, Akahoshi, Miyasaka, & Suzuki, 2011;Wigger-Albert et al., 2009), topical silicone gel (Karagoz et al., 2009), pressure gar-ments (Engrav et al., 2010), and a combination of these therapies (Li-Tsang, Zheng,& Lau, 2010). As no single best method for scar management has been identified,the therapist will need to collaborate with the health care team in identifying thebest intervention for a particular patient situation in the NICU and should bevigilant in following the literature to identify the most appropriate evidence-basedstrategies.

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Promote Contained Movement

The promotion of contained movement is another component of developmentallyappropriate positioning and handling of preterm infants with limited endurance andimmature capacity to control more complex antigravity movement. This interven-tion differs from the previously discussed calming measure referred to as contain-ment. Contained movement refers to free movement with boundaries that typicallylimit the motion within mid-range for protection and support. Regardless of age,most medically fragile infants with limited tolerance of handling can benefit frompromotion of contained movement during their positioning and routine care. Thecycles of active movement that are typically evident to mothers during their thirdtrimester of pregnancy play an important role in fetal musculoskeletal and nervoussystem development. Fetal ultrasound images during the third trimester of preg-nancy confirm that movements are typically vigorous, complex, and variable whilebeing limited in range by the uterine wall. The rationale for promotion of containedmovement is provision of a similar though diminished developmentally significantexperience. Using the qualitative assessment of General Movements developed byPrechtl and colleagues, a variety of smooth, multi-directional fetal movements ofthe head, trunk, and extremities were observed in utero as well as among infantsborn preterm as young as 24 weeks PMA (de Vries & Bos, 2010; Prechtl, 1990).The uterine wall not only limits the arcs of extremity movements, but also facili-tates flexed resting postures between cycles of fetal movement.

When prematurely born infants are at rest and not being disturbed by caregivers,nested bedding is the primary uterine wall substitute for support of flexed postures,midline orientation, and limitation of extremity movement. A study comparingthe posture and movement responses of preterm infants demonstrated benefits ofnested support (Ferrari et al., 2007). The positioning method used by Ferrari et al.(2007) consisted of a relatively deep oval nest completely surrounding the infantfrom head to toe with space for movement while supine. The authors concludedthat when “nested,” infants not only maintained resting postures with greater ex-tremity flexion, but also initiated spontaneous movements with more midline orien-tation and isolated distal components as well as initiated fewer abrupt or end rangeextremity extension movements. The primary effect among 30–33 weeks PMA in-fants supported by nested bedding was increased extremity movements toward themidline and isolated distal movements of the wrists. Among infants 34–36 weeksPMA, abrupt, spontaneous startle movements were significantly decreased as anadditional benefit. A finding specific to infants at 37–40 weeks PMA was restingpostures before and after spontaneous movement that included increased shoulderadduction and head alignment in midline.

During routine care of preterm infants <35 weeks PMA, several rest periods withcontainment measures provided by the hands of a caregiver are typically needed forcalming while vital signs return to baseline levels. Smooth, small-arc movements ofextremities toward the midline and active trunk flexion signal not only a preterminfant’s recovery from the stress of routine care measures but also a drive to moveand enjoyment of controlled movement. When these behaviors are observed, briefuninterrupted periods to engage the infant in free but contained movement can beof benefit. For example, an infant supported in a flexed sidelying position with a

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surface against which to kick (adult’s hand) can experience variable, smooth move-ment typical of <35 weeks PMA infants. By modeling this technique, a therapistintroduces caregivers to options other than swaddling that may significantly limitdevelopmentally important extremity movement.

Provide Gentle Range of Motion as Indicated and Splinting as Needed

Some infants born preterm require gentle range of motion due to contracture orprolonged immobility (e.g., the very ill infant sedated and “paralyzed” for recov-ery). As an expert in the musculoskeletal system, the physical therapist is qualifiedto provide this intervention, but the neonatal musculoskeletal system is fragile andvulnerable to injury. Providing passive range of motion can put the neonate at riskfor fractures (Dabezies & Warren, 1997). A special consideration for infants bornpreterm is that they have cartilaginous joints at the wrists and ankles (Buckwalter,1994). In addition, infants born preterm are at greater risk for developing osteope-nia. Clinical evidence of mineral bone deficiency has been demonstrated in 30–50%of infants born with very low birth weight (VLBW) who are fed unfortified humanmilk (Hawthorne, Griffin, & Abrams, 2004; Koo et al., 1988), so particular care mustbe taken when providing range of motion. Often in consultation with occupationaltherapy, splinting is reserved for contracted joints or used as an immobilization aideas needed (e.g., to stabilize fractures; Dabezies & Warren, 1997).

Facilitate Periods of Exploratory Moving

The promotion of exploratory movement without boundaries is another importantcomponent of developmentally appropriate positioning and handling. With proxi-mal support, maturing preterm infants benefit from unrestrained movement withthe demands of gravity reduced. Strength and control gained by exploratory move-ment experience form a bridge for the infant to begin more complex antigravitymovement.

With trunk and neck support provided in supine, prone, or sidelying positions,a preterm infant can enjoy the freedom to move one or more extremities withoutboundaries imposed by blankets, nested bedding, or caregiver’s hands. In supine ly-ing, support of the head in midline and containment of the upper extremities closeto the trunk can enable an infant to explore a wider variety of lower extremitymovements than otherwise tolerated. Also in supine lying with containment of allthe extremities, provision of a neck roll can encourage an infant to engage in side-to-side neck rotation, orientation to voices, and to briefly hold a midline position.While sidelying with trunk support, the un-weighted upper arm and leg are freeto move. Initially, preterm infants typically respond best to free movement of onlyone arm or leg in this position. Some infants find horizontal sidelying particularlychallenging and often more so on one specific side. Poor tolerance of sidelying canbe due to restricted expansion of the lower, weight-bearing rib cage, delayed gastricemptying, or gastroesophageal reflux. Elevation from horizontal sidelying or supinelying on a firm surface to a 30–40 degree angle can allow improved expansion ofthe rib cage as well as relieve gastric problems (van Wijk et al., 2007). Exploratorymovement in supine lying is more demanding than in prone for infants with pul-monary insufficiency requiring supplemental oxygen. In prone position, infants whoare oxygen-dependent have higher lung volumes and functional residual capacity

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that improves oxygen saturation and reduces the effort of breathing (Bhat et al.,2003). Among healthy preterm infants, however, the cardiopulmonary demands ofdifferent positions seem to be clinically insignificant (Dolberg, Yacov, Mimouni, &Barak, 2004; Levy et al., 2006). In prone lying with head, neck, and trunk ventrallysupported as well as elevated off the support surface to shift weight off the lower ex-tremities, infants can explore kicking without boundaries to push against. In pronelying at 30–40 degrees incline, stabilization of the extremities close to the trunk canallow an infant to explore head lifting with variable degrees of rotation.

Promote Alerting and Interaction

Promoting infant alerting for various developmental tasks such as feeding,environmental exploration, and social interaction with family is a role for thephysical therapist in the NICU. Facilitating infant state regulation so that theinfant achieves a calm alert state (Brazelton Level 4) can be done through variousinterventions (Brazelton & Nugent, 1995). Researchers have shown that a carefullyimplemented program consisting of auditory (soothing voice), tactile (massage),visual (attempted eye contact), and vestibular (horizontal rocking; ATVV) stimulican promote alerting in healthy convalescing preterm infants (White-Traut,Nelson, Silvestri, Cunningham, & Patel, 1997; White-Traut, Nelson, Silvestri,Patel, & Kilgallon, 1993). This research (please refer to the articles for moredetail regarding the protocol used) has since been expanded to include extremelypreterm infants (born at 23–26 weeks GA) and preterm infants with intracraniallesions (White-Traut et al., 2002). In the latter study, the infants receiving ATTVdemonstrated significantly increased alerting during the intervention that wassignificantly correlated with reduced length of stay. In addition, the proportion ofnipple feeds increased significantly faster for infants in the study group than thosein the control group (White-Traut et al., 2002).

Despite these positive findings, the therapist must take care not to overstimu-late the infant or create physiologic instability. Sensitivity to infant behavioral andphysiologic cues is critical. In addition, it is necessary for the therapist to remem-ber that a preterm infant may have a delayed reaction to an intervention so oneshould ascertain the effects on sleeping patterns and feeding after the stimulation.When implementing an ATTV program to encourage infant alerting, it should benoted that White-Traut et al. (1997) found that tactile stimulation alone was toostimulating and that the vestibular component helped modulate the overall sensoryexperience of the preterm infant.

MOVEMENT THERAPY

It is important for the infant to have opportunities for movement, both guided andfacilitated and self-initiated (with protective boundaries). These movement oppor-tunities are provided in the context of varying the infant’s position (e.g., supine,sidelying, prone, supported upright). The next section of this article presents phys-ical therapy interventions from the Movement Therapy portion of the Infant CarePath for Physical Therapy in the NICU (Campbell, 2013; Figure 4).

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Physical Therapy Intervention In Neonatal Intensive Care Unit 89

FIGURE 4. Movement Therapy, Intervention section of the Infant Care Path for PhysicalTherapy in the NICU. Source: Campbell (2013).

Guided Extremity Movements

Development of strength may be facilitated by guided flexion and extension move-ments of the infant’s lower extremities, similar to a bicycle riding pattern, initiallyperformed with hands placed around the knee joint for protection. During this ac-tivity, as the infant begins to actively kick, the physical therapist’s hands move to theplantar surface of the foot in order to give tactile and proprioceptive input as theinfant gently kicks. This provides the infant with a surface to extend against. Thismovement does not involve traction or joint compression, and it is not explicitlyresistive. The maneuver is meant to mimic what infants experience when pushingagainst the intrauterine wall. The purpose of this exercise is to facilitate both freekicking and guided contained kicking, movements the infant is free to perform inutero, but that are limited by the constraints of swaddling and the force of gravityin the NICU. These flexion and extension movements of the legs may be beneficialfor joint molding, because after birth infants born preterm do not experience theresistance of the fluid-filled utero environment (Sweeney & Gutierrez, 2002). Inaddition, the opportunity for the infant to gently push against their parent’s hand(similar to pushing against the intrauterine wall) may help decrease bone deminer-alization (Litmanovitz et al., 2003; Moyer-Mileur, Brunstetter, McNaught, Gill, &Chan, 2000), as research showed that guided range of motion exercises for VLBWinfants decreases osteopenia.

Increased Time in Upright Position

The infant’s tolerance of upright positioning is important for multiple caregiving sit-uations. Supported sitting is developmentally beneficial because it will (1) facilitatethe use of the neck rotator and extensor muscles, which may foster development ofhead control; and (2) promote an alert and visually oriented behavioral state (Shea-han & Brockway, 1994). Prior to 35 weeks PMA, most preterm infants initially ex-perience the upright position for brief periods during routine care within their iso-lette and while being held by a parent or other caregiver. Schrod and Walter (2002)investigated concern that movement from horizontal lying to vertical is associatedwith orthostatic stress in fragile preterm infants. Reassuringly, they reported no clin-ically significant autonomic or cerebral oxygenation effects among infants less than1,500 g during the first week of life at 30 degrees elevation of the whole body.

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FIGURE 5. This position provides upright support of the infant facing away from thecaregiver with their back and head against the caregiver’s chest and anterior support ofthe infant’s chin and trunk provided by the caregiver’s hand. In response to this support,the infant pictured is actively bringing her head toward vertical midline.

At approximately 35 weeks PMA, preterm infants typically increase their up-right position time as they gain competence in nipple feeding. With experienceand maturation, the infant’s responsive periods during supported sitting can ex-pand from 1 min to 2 min in the middle of a feeding to 10–15 min periods followingfeeding several times each day. With trunk support and freedom to move in sup-ported upright, spontaneous head righting effort and exploratory movements withextremities can gradually increase in frequency and duration. While a swaddled in-fant is held by a caregiver, there are many variations of upright positioning that canbe used. Typically, the most easily tolerated position for an infant is upright proneat the caregiver’s shoulder. Another involves upright support of the infant facingaway from the caregiver with their back and head against the caregiver’s chest andanterior support of the infant’s chin and trunk provided by the caregiver’s hand(Figure 5). A supportive type of semi-upright lap sitting requires the caregiver’s feetto be elevated by a stool in order to provide the infant with full posterior supportof their head and trunk while looking toward the caregiver. Supported lap sittingfrom semi-upright to full upright with the adult’s hands providing variable degreesof anterior and posterior trunk and neck support is the most challenging for younginfants (Figure 6).

As infants’ interest in the world around them exceeds the time parents, staffmembers, and even volunteer caregivers have available to hold them upright, use ofinfant seats and swings often begins. These devices have both advantages and disad-vantages that should be acknowledged by nurses and therapists as well as explained

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FIGURE 6. While full trunk support is provided by adult hands, gentle lifting of the uppertrunk aligns the spine in vertical, limits increased pressure on the stomach, and elongatesmuscles of the trunk. This can in turn facilitate head righting and interactive orientationresponses as well as burping.

to parents. The seats frequently need positioning devices or multiple blanket anddiaper rolls to maintain midline alignment of the infant’s neck and trunk as wellas support their shoulder and pelvic girdles. Young infants can tire rapidly in theseseats and with fatigue their tolerance of environmental and social stimulation de-creases. With supportive positioning and gradually increasing time in these devices,young infants can benefit from the increased upright positioning time in swingsand infant seats. Once infants gain endurance for upright positioning, they may be-gin to modulate postural responses as well as alter their extremity movements asthe degree of external trunk support and the angle of sitting change. As infantsincrease their time in upright positions, therapists can instruct parents to observesigns of their infant’s maturing movement control as well as fatigue and discussthe value and drawbacks of time spent in swings and infant seats following hospi-tal discharge. Investigating the relationship between infant play-equipment use, fa-vored play positions, and motor development, Bartlett and Kneale-Fanning (2003)found that following hospital discharge, a large percentage of preterm infants spentmore time sitting in swings and infant seats as well as carried in a sitting positionthan other play positions. The authors were unable to identify a cause versus effect

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relationship, but concluded that lack of sitting ability contributed to an infant’s pref-erence for prolonged carrying or supportive seating while the extended periods ofcarrying and equipment use limited the infant’s opportunities for development ofindependent sitting ability.

Varied Developmental Positions

Although preterm infants benefit from spending gradually increasing time in sup-ported upright positions, they should experience movement in prone, supine, andsidelying to promote motor development and prevent secondary impairments suchas plagiocephaly and torticollis. Preterm infants 35 weeks PMA and older spendincreasing amounts of time sleeping in supine and feeding in supported upright po-sitions. Consequently, effort may need to be directed toward providing the infantexperiences moving in prone and sidelying.

One strategy that we have found successful is to vary the position in which the in-fant is held, especially by their parents. When providing SSC in semi-upright prone,the direction the infant faces should be alternated between right and left, especiallyif the infant prefers rotation to one side. Infants also benefit from variation in cra-dled holding positions. Right-handed caregivers tend to hold infants with their leftarm, leaving their more dexterous right hand free for manipulative tasks. An in-fant cared for by primarily right-handed people can become adept at orientationto voices and movement toward their own right side while ignoring the majorityof input from the left (Hummel & Fortado, 2005). These caregiving patterns withunidirectional stimulation can contribute to the progression of plagiocephaly. Al-though it feels awkward initially, encouragement of right-handed parents to cradlethe infant with their right arm provides that infant with social stimulation to whichthey can respond from the left side.

As infants begin to lift their head while held against a caregiver’s shoulder, thisrighting response is optimally facilitated from each of the adult’s shoulders. Imma-ture head righting effort is often characterized by rotation to one side rather thana midline position. While lifting their head, infants also tend to rotate toward thedirection of their caregiver’s voice or face. The pattern of simply placing an infantwith their head at opposite ends of their bed every other day or following each feed-ing during the day is helpful to present different environmental stimulation and aidbilateral orientation by the infant. As previously mentioned, sitting with trunk sup-port from a caregiver is a very different task for an infant than upright placementin a swing or infant seat with either a molded plastic or a cloth hammock seat. Nev-ertheless, each of these positions provides a variety of postural challenges for aninfant, opportunities for antigravity upper extremity movement, and engagementwith social or environmental stimulation from varied directions.

Before discharge from the NICU, the majority of preterm infants enjoysemi-prone snuggling and movement on a caregiver’s lap or chest. The challengeof prone head righting is reduced and head lifting to find a familiar voice ismore easily facilitated in this semi-prone position at approximately a 45 degreeangle. Time for continuation of this experience needs to be incorporated into theinfant’s daily routine in anticipation of their discharge especially as they spendmore time sleeping in supine. The addition of prone play or rest time followingnipple feeding can be encouraged and modeled for parents by therapists as well

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Physical Therapy Intervention In Neonatal Intensive Care Unit 93

as nursing staff. The importance of supine sleeping is usually modeled for andemphasized to parents prior to the time of a preterm infant’s hospital discharge.Ideally, this instruction is coupled with acknowledgment of the importance of“tummy time play.” Handouts on tummy time activities in multiple languagesare available at http://www.pathways.org/awareness/parents/tummy-time as well asfrom Children’s Healthcare of Atlanta at http://www.choa.org/childrens-hospital-services/orthopaedics/programs-services/orthotics-and-prosthetics/tummy-time-tools.

The importance of variable play positions on sensorimotor development is ev-ident in studies of typically developing infants. Majnemer and Barr (2005) deter-mined from analysis of parentally completed “infant behavior diaries” that proneplay or “tummy time” was seldom incorporated into an infant’s daily routine. Atfour months, more than 30% of 52 infants were never placed in prone and 75%spent less than 20 min in prone daily. Majnemer and Barr also determined thatthe average time four- to six-month-olds spent in supported swing or infant seatsitting was 4 hr per day. In general, infants with little or no prone activity timescored lower on the Alberta Infant Motor Scale (AIMS) at four months and onthe Peabody Developmental Motor Scales (PDMS) at six months. Another investi-gation among typically developing term infants at four months revealed that mostof their alert time was spent being held and supported in sitting (Dudek-Shriber &Zelazny, 2007). Sixty of the 100 infants spent 30 min or less in prone daily. In com-parison, the median time infants were held in sitting was two-and-a-half hours dailyin addition to the three-and-a-half hours they spent positioned in sitting each day.Infants who spent less than 1 hr and 20 min in prone were more likely to demon-strate delayed antigravity skills in prone, supine, and sitting as measured by theAIMS. The influence of positioning on early development of full-term infants doesnot necessarily have long-term consequences. The results nevertheless do supportpositioning and the environment of play as important for infants at risk for devel-opmental delays.

In a study of caregiver handling of preterm infants during dressing, bathing, andplay, Murney and Campbell (1998) reported infrequent use of the prone position.The limited ability of infants with diffuse or focal CNS damage to enjoy move-ment play in a variety of positions is a consideration when planning interventions.Comparison of age- and gender-matched infants three- to eight-months-old withand without positional plagiocephaly revealed a significant difference in support-ive sitting time in infant seats and swings but not in prone playing time (Kennedy,Majnemer, Farmer, Barr, & Platt, 2009). Most of the infants studied spent brieftimes playing in prone, but development of more mature motor skills as measuredby the AIMS was positively correlated with prone play duration regardless of pla-giocephalic deformity. Fetters and Huang (2007) investigated the influence of sleep,play, and feeding positions on motor development through nine months CA in low-risk term infants and preterm infants with and without white matter disease (WMD)such as periventricular leukomalacia (PVL). Supine sleeping did not have a nega-tive effect on motor development while prone sleep and play had a positive effect.The majority of the infants played and were fed in either supine or sitting. A largepercentage of infants slept in prone at least part of the time and this is reflected inhigher AIMS scores at one month regardless of GA at birth or CNS status. At five

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months, sleeping and playing in prone were associated with higher AIMS scores.At nine months, a predominance of play in sitting was negatively associated withAIMS scores.

Although the studies cited primarily focus on infant development between fourand nine months, family education and instruction at the time of the infant’s dis-charge form the foundation for the practice of varying sleep, play, and feedingpositions until the infant becomes mobile. Through a preterm infant’s hospitalcourse, persistent irritability in any position can be a signal of discomfort or stressthat should be evaluated. Sources of infant irritability in a particular position in-clude: GERD, constipation, intestinal gas, atelectasis, fatigue from increased workof breathing, weakness and inability to move because of too much or too little con-finement, too little stability, and limited or too much sensory input. With an under-standing of the source(s) of irritability, therapists can modify the position or envi-ronment and reintroduce the experience. They can, in turn, help parent to do thesame rather than simply avoiding new or challenging experiences for their infant.

Enhancement of Trunk Mobility and Diaphragmatic Breathing

Adequate diaphragm control for ventilation is required in order for an infant toenjoy movement during periods of alertness. Adequate lower esophageal sphincterfunction and diaphragm control are needed to prevent reflux of gastric secretionsand food into the esophagus or pharynx while the infant’s trunk provides a stablebase for extremity or neck movement. These challenges are most evident amongbut not limited to infants with GERD and CLD or bronchopulmonary dysplasia(BPD). Premature birth is associated with reduced lung function during at least thefirst months of life (Friedrich, Stein, Pitrez, Corso, & Jones, 2006) and some levelof airway obstruction has been identified in pulmonary function studies of preterminfants with no history of neonatal respiratory disease. Friedrich and colleagues(2006) determined that for each week of increased GA at birth, preterm infantsgain an average 7% increase in mid-range forced expiratory flow or the efficiencyof exhalation. Limitations in air flow were thought to result from persistently smalldiameter airways in the distal bronchial tree as well as decreased stability of thesesmall airways (Friedrich et al., 2006). In other words, most prematurely born infantsmove less air out of their lungs during exhalation than a comparable size full-terminfant would.

Among preterm infants 34 weeks PMA and older, a challenge to antigravitymovement is that postural muscles are often used as assistive respiratory muscles.With an increased oxygen requirement imposed by active movement or nipple feed-ing, increased respiratory rate and recruitment of accessory respiratory musclessuch as the trapezius and levator scapulae are more likely to occur. In additionto decreased efficiency of exhalation due to small, distal airway obstruction, infantswith CLD can develop altered breathing patterns including a longer delay betweendiaphragmatic contraction and detectable initiation of inspiratory air flow, possiblybecause of decreased lung compliance (Hutten et al., 2010). In our experience, tho-racic spinal extension and scapular retraction are postures used by preterm infantsto stabilize the chest wall in an attempt to improve the efficiency of diaphragmaticcontraction during active movement and nipple feeding. This, however, often lim-its the infant’s exploratory extremity movements, and swallow-breath coordination

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FIGURE 7. By distraction of the lower ribs toward the pelvis in a manner similar to maturelycoordinated abdominal muscles, the diaphragm has a more stable base from which tofunction and the extremities have more proximal stability from which to move. In thispicture, costal border support is used to support the infant’s tolerance of supine lying.

while nipple feeding. Consequently, fatigue as indicated by irritability, drowsiness,tachypnea, increased work of breathing, and/or diminished coordination shouldbe anticipated among preterm infants. As the preterm infant engages in moreantigravity movement during routine care as well as attempts the intake of largervolumes by nipple feeding, the infant’s need for more frequent and/or longer dura-tion rest periods also should be anticipated.

The supine position is particularly challenging for infants with CLD, GERD, orboth of these conditions. Using the maximum inspiratory pressure as a direct mea-sure of diaphragm strength or work load, Dimitriou and colleagues (2002) foundsupine and semi-upright supine to be more demanding than prone lying, but thatoxygen saturation was significantly higher in semi-upright positions in comparisonto supine lying. Clinically, caregivers observe that some infants recover from lowoxygen saturation rapidly in supine while nested in a quiet alert state but requireadditional oxygen support during routine care or feeding. Tolerance of supine canbe improved by elevation of the head of the bed as well as planning interventionbefore feeding occurs. During periods of supine movement and rest, therapists andother caregivers can assist by stabilization of the lower ribs in alignment with thepelvis. By distracting the lower ribs toward the pelvis, a function of the abdominalmuscles, the diaphragm has a more stable base for contraction and the legs havemore proximal stability from which to move (Figure 7).

While supine or semi-upright in a caregiver’s lap, an infant’s midline head, trunk,and pelvic alignment can be supported by the positioning of the caregiver’s legs.

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FIGURE 8. This infant is in a position of semi-upright supine on a caregiver’s lap. Thecaregiver is sitting in a chair with their feet on a stool that places the infant at approximatelya 45 degree angle. With the infant supported in this position, their muscles of shoulderelevation and scapular retraction can be gently lengthened as the caregiver passivelylowers and adducts the shoulders as well as protracts the scapulae. With the use ofthese accessory respiratory muscles limited, the infant can experience upper extremitymovement toward the midline while depending upon diaphragmatic breathing.

With this support provided, the therapist can then gently lengthen the muscles ofshoulder elevation and scapular retraction while passively lowering and adductingthe shoulders as well as protracting the scapulae. With the use of these accessoryrespiratory muscles limited, the infant can experience upper extremity movementtoward the midline while depending upon diaphragmatic breathing (Figure 8). Withtrunk and pelvic alignment maintained in supine, a therapist can facilitate abdomi-nal muscle control by gently lengthening spinal extension muscles with passive ele-vation of the pelvis in a posterior tilt. From this position, the infant can experiencemidline head and trunk orientation and/or lower extremity movement while de-pending upon diaphragmatic breathing (Figure 9). Simply trusting their ventilatorycapacity in supine or elevated supine positions without assistive respiratory mus-cles is a stressful challenge for some infants to meet before extremity movement orsocial interaction is possible.

Sidelying presents a ventilatory challenge for some infants with GERD as wellas those with persistent pulmonary insufficiency. The infant may initially preferone side to alleviate reflux symptoms or decrease demand on areas of chronic pul-monary infiltration or atelectasis. As feeding volume requirements increase, eachsidelying position presents a different challenge for infants with reflux. Right side-lying facilitates gastric emptying immediately following feeding but can also facil-itate reflux. Left sidelying can delay gastric emptying but avoid reflux (van Wijket al., 2007). In our experience, because a neonate’s rib cage is flexible and primarily

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FIGURE 9. With trunk and pelvic alignment maintained in supine, a caregiver canassist immature abdominal muscle control by gently lengthening spinal extension mus-cles with passive elevation of the pelvis into a posterior tilt. From this position, the infantcan experience midline head and trunk orientation and/or lower extremity movement.

cartilaginous, the volume of the weight-bearing side of the chest can be significantlydecreased in sidelying. Furthermore, we have observed that an infant may be com-fortable resting on the side of diminished pulmonary function, but irritable restingon the other side with limited expansion of lobes depended upon for compensation.Even after the pulmonary condition has resolved or reflux symptoms have been ef-fectively treated, habitual breathing patterns and limited soft tissue extensibilitymay persist and be reflected in poor tolerance of a specific sidelying position.

In order for an infant to maintain adequate ventilation in sidelying without ac-cessory respiratory muscle use and trunk extension, elevation of the head of thebed is once again an important first step. While posteriorly cupping the infant’shead and pelvis, a therapist can passively flex the thoracic spine to neutral. Main-taining adequate oxygen saturation without tachypnea and tachycardia is the initialgoal. Because accessory respiratory muscle use is typically symmetrical, the sidely-ing position may limit the infant’s reliance on accessory muscles. The infant’s ownweight is usually sufficient to cup the lower shoulder anteriorly and protract thescapula. When ventilation is not a challenge in sidelying, an infant can interactwith caregivers and enjoy exploratory movement of the un-weighted arm and leg.While being held by a caregiver in sidelying, the problem of restricted ventilationof the lower, weight-bearing chest can be resolved by simply elevating the infant. In

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FIGURE 10. While being held by a caregiver in sidelying, the problem of restrictedventilation of the lower, weight-bearing chest can be resolved by simply elevating the infantto approximately a 45 degree angle. In this elevated sidelying position, the weight-bearingshoulder can be held in overhead flexion with the scapula protracted to limit accessoryrespiratory muscle use while ventilation is no longer restricted.

elevated sidelying, the weight-bearing shoulder can be held in overhead flexion withthe scapula protracted to limit accessory respiratory muscle use (Figure 10). Ele-vated sidelying with lateral trunk flexion is a position in which ventilation of thelower lung is enhanced. While gaining endurance in this position may be an initialgoal for an infant with CLD, alternate positioning to each side can become a valu-able rest and recovery position for the infant during nipple feeding or antigravitymovement.

Prone lying is frequently the preferred position for rest and recovery among in-fants, especially those with GERD and CLD, but horizontal prone can be a chal-lenge. In elevated prone with the head above the stomach level, reflux symptomsare less likely to occur. This elevated prone position can occur on a caregiver’s chest,at their shoulder, across their lap, or in the infant’s bed. By gently positioning botharms overhead while the infant is in an elevated prone position, the scapulae are bi-laterally protracted, use of accessory respiratory muscles is limited, and diaphragmfunction is enhanced. Initially, some infants only tolerate overhead flexion of thearm on one side. An additional benefit of positioning the infant across a caregiver’slap is the potential to eliminate any pressure on a full stomach that enhances di-aphragm excursion for inspiration and decreases the potential for emesis. If theinfant is not trying to actively lift their head, flexion of the trunk can occur as theinfant relaxes across the caregiver’s thigh (Figure 11). In this elevated prone posi-tion, the infant can burp and pass gas and stool with decreased potential for eme-sis following feedings. An infant can also fall asleep, engage in head lifting and/or

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FIGURE 11. By gently positioning both arms overhead while the infant is in an elevatedprone position, the scapulae are bilaterally protracted, use of accessory respiratory musclesis limited, and diaphragm function is enhanced.

kicking, as well as enjoy deep tactile stimulation of their back and soles of their feetin this elevated prone position. Infants can be carried in an elevated prone positionwith overhead shoulder flexion, weight off the abdomen, and the head elevatedabove the stomach (Figure 12). In our experience, parents coached through and re-inforced for use of elevated prone positions following feedings seem to transitionwell to “tummy time play” at home.

Promotion of Antigravity Movements

Green, Mulcahy, and Pountney (1995) provide evidence that typical infant devel-opment includes a relatively predictable progression of increasing postural stabil-ity, controlled weight shifting, and isolated limb movement. More than 90% of thedevelopmental changes they observed among 18 infants with typical developmentoccurred after postural control was concurrently evident in both prone and supine.Their results suggest that strength and postural control in both prone and supineare required before even brief symmetrical sitting is achieved. Green et al. also ob-served that functional movement was influenced by the surface upon which an in-fant was placed and that infants initially reverted to less mature postures when per-forming movements associated with orientation, reaching, and contact responseswith either their hands or feet.

Characteristics of preterm infant’s early antigravity movements have been doc-umented and compared between full term and preterm infants. From two to fourmonths CA, significant differences between full term and preterm infants are ev-ident in postural adjustments and in extremity movements during reaching and

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FIGURE 12. Infants can be carried in this elevated prone position with weight off theabdomen and the head elevated above the stomach. This infant has responded to theposition of the caregiver’s arm by upper extremity flexion with shoulder internal rotationand adduction. Positioning both shoulders in greater overhead flexion over the caregiver’sarm than is illustrated by this photograph, can limit accessory respiratory muscle use whilean infant recovers from the work of feeding or a stressful event.

kicking (Fallang, Saugstad, Grogaard, & Hadders-Algra, 2003a; Heathcock, Bhat,Lobo, & Galloway, 2004; Heathcock, Bhat, Lobo, & Galloway, 2005). Dusing,Mercer, Yu, Reilly, and Thorpe (2005) compared supine trunk positions of 18preterm infants with those of 15 full-term infants at 40–43 weeks PMA and foundthat full-term infants maintained trunk positions of flexion or neutral approxi-mately two-thirds of the time and rolled to sidelying more frequently than preterminfants. The motor behavior of the preterm infants corresponded to the least maturelevel of supine posture control described by Green and colleagues (1995). Dusingand colleagues (2005) found that prematurely born infants around 40 weeks PMAdo not spend more time in extension positions as popularly thought, but they doroll from supine to sidelying less often than infants born at term. Comparing six-month-old prematurely born infants with full-term infants, Fallang, Saugstad, andHadders-Algra (2003b) identified persisting differences in weight-shifting patternswhile reaching.

Early patterns of spontaneous arm waving and kicking provide the basic pat-terns that infants elaborate into more complex, controlled reaching and environ-mental exploration with both hands and feet. Links between these initial sponta-neous antigravity extremity movements and early cognitive skills as well as complexprehension and manipulative skills have been confirmed by research (Heathcock &

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Galloway, 2009; Heathcock, Lobo, & Galloway, 2008). Associations between initialwalking patterns and kicking as well as supported treadmill stepping response char-acteristics have been confirmed by several studies (Jeng, Chen, Tsou, Chen, & Luo,2004; Luo et al., 2009). There is also evidence, however, that differences remainbetween preterm and full-term infants as they develop reaching and locomotionskills that are neither consistent nor predictive of significant morbidity or guaran-tees of normality (Fallang et al., 2003a).

Between 35 and 37 weeks PMA, as preterm infants gain endurance and tol-erate multiple positions without physiologic compromise, they begin to includemore antigravity components in their exploratory movements. Emerging posturalresponses can be evident during transitions out of and back into the infant’s bed aswell as during supported upright at various angles during feeding and carrying. Inassociation with diaper and clothing changes, vigorous extremity movements un-related to stress behaviors seem at times to make the process quite difficult. It isduring these periods of routine caregiving while infants are alert for expanding pe-riods of time that therapists can teach parents to wait for responses as well as themethods to facilitate their infant’s antigravity movement within these functionalcaregiving activities.

The opportunities for preterm infants to engage in antigravity movement dur-ing caregiving in the NICU environment as well as post-discharge have been doc-umented as part of an investigation of the construct validity of the Test of InfantMotor Performance (Murney & Campbell, 1998). Following analysis of videotapesof caregiving activities (bathing and dressing) and interactive play scheduled 1 hrbefore feeding, the authors determined that the average duration of handling was13.9 min with a range of 7 min to 18 min among infants 33–41 weeks PMA. The ma-jority of infants in the entire sample from 33 weeks PMA to 12 weeks CA were ex-posed to at least three different positions during each cycle of care and play. Among35–37 weeks PMA infants preparing for hospital discharge as well as during theirinitial weeks following discharge, these handling periods occur at least eight times aday in association with their need to feed approximately every 3 hr. Consequently,infants can have multiple 10–15 min opportunities for antigravity movement and in-teractive responses daily if their caregivers assist them with proximal stability andwait for their active responses.

As infants reach 35–37 weeks PMA, one of the first measures needed to enhancetheir persistence in spontaneous antigravity extremity movement is gradual elimi-nation of restrictive swaddling and nested bedding. As these same infants transitionout of an isolette and into an open bed, nesting needs to be gradually eliminatedso infants can experience spontaneous movement against a firm surface and gainself-calming capacity. The findings of Green and colleagues (1995) identify differentresponses to a firm surface among infants with less mature levels of postural con-trol in contrast with those having more mature levels of control. The swaddling andnesting that helps calm infants may also provide shoulder and pelvic support theystill depend upon for control of their posture and extremity movement. A similardegree of nesting may however frustrate a more mature infant who is able to shifttheir center of gravity and isolate extremity movements provided the opportunityon a firm surface.

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Promotion of Supine Anti-Gravity Movement

Among maturing preterm infants, supine antigravity movements typically occurwith more control in the lower extremities before the upper. The possible reasonsfor this are discussed by Heathcock and Galloway (2009) in their comparison offoot reaching with hand reaching skill development among four- to six-month-oldinfants. In order for less than 40 weeks PMA infants to kick and reach while supine,they typically need trunk and proximal joint stability before they are able to transi-tion from movements in a relatively horizontal plane into more vertically directedmovements. Antigravity leg movement can be encouraged by a caregiver assist-ing the abdominal muscles with lifting the pelvis into a posterior tilt. Antigravityarm movement can be encouraged by a caregiver assisting the pectoral muscleswith cupping the shoulders ventrally. These two Neurodevelopmental Treatmentor NDT-based facilitation methods are explained in detail by both Bly (1999) andBoehme (1990). Rather than deciding upon a specific time or duration for anti-gravity movement, therapists can assist parents in identification of optimal timesduring caregiving for support of antigravity extremity movement. By teaching par-ents methods for proximal support, they can help their infant extend the durationand variation of extremity movement multiple times daily in the functional contextof caregiving.

Promotion of Prone Antigravity Movements

Prone antigravity movements typically include neck rotation and head lifting withincreasing degrees of thoracic spinal extension as the infant matures and gainsstrength. These movements typically occur while a caregiver supports an infantprone on their chest or lap at variable angles to the horizontal plane as well aswhen a caregiver holds them suspended in open space during multiple caregivingtasks. The extent to which both an infant’s trunk stability and trunk-to-pelvic align-ment are assisted by the caregiver is reflected in the quality and duration of theinfant’s head lifting and interactive orientation responses. Placement of one of thecaregiver’s hands firmly over the infant’s pelvis and hips may provide sufficient sta-bility to encourage head lifting as the visual stimuli or the angle of the caregiver’slap change. Additional stability and alignment assistance can be provided by thecaregiver’s hands positioned firmly at one or both sides of the trunk, distracting theinfant’s lower ribs down toward the pelvis and assisting caudal-ward weight trans-fer. These are also NDT-based methods for facilitation of head lifting in prone thatare explained in detail by both Bly (1999) and Boehme (1990).

Promotion of Antigravity Movements in Supported Sitting

Assistive measures for increasing an infant’s tolerance of and endurance in the sit-ting position as well as methods to facilitate head lifting and extremity movementsin stationary sitting are discussed previously in this article in Section “Increasedtime in upright position.” Typical caregiving routines at the time of discharge, how-ever, also include transitions into and out of sitting as well as movement throughspace while in a sitting position. The complexity of an infant’s responses to thesetransitional movements varies with the support and alignment assistance providedfor the trunk and neck, with the angle of the head and trunk relative to vertical,

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and with the degree of free movement allowed for the extremities. Therapists canteach a caregiver to lift their infant or move them from supine or prone into sittingwhile providing trunk to pelvic alignment and stability as well as to pause duringthe movement and wait for the infant’s emerging neck rotation or lateral flexionresponses. These NDT-based methods for facilitation of postural responses duringmovement in and out of sitting, carrying, kicking, and reaching in supported sittingare also explained in detail by both Bly (1999) and Boehme (1990).

Neurodevelopmental Techniques

Neurodevelopmental treatment or NDT techniques are appropriate to includewithin movement therapy as preterm infants reach 35–37 weeks PMA (Figure 3).These techniques have already been described in the previous section as the ba-sis for many of the methods employed by therapists to promote antigravity move-ments. Although in wide use and woven into the treatment repertoire of many phys-ical therapists, NDT as a primary intervention program within the NICU neverthe-less lacks the support provided by statistically significant, measurable long-termresults from large randomized controlled trials.

A controlled clinical trial provides support for the application of an NDT pro-gram for preterm infants in the NICU (Girolami & Campbell, 1994). The studyis referenced as evidence supporting movement intervention in the guidelines forNICU practice (Sweeney, Heriza, Blanchard, & Dusing, 2010). The preterm infantswere at high risk for long-term developmental delay and had three or more posi-tive neurological findings on the Neonatal Behavioral Assessment Scale (NBAS)at 34–35 weeks PMA. Nine preterm infants received NDT, 10 preterm infants re-ceived social stimulation, and eight full-term infants received no intervention. Theintervention (Girolami & Campbell, 1994) was designed to improve head control,midline orientation, hands-to-mouth activity, and antigravity movements of the ex-tremities. The preterm control group received social stimulation in each of the fourpositions. NDT-based treatment or social stimulation was provided twice daily forup to 15 min for at least seven but up to 17 days. Following intervention, infantswere evaluated by examiners blind to group assignment using the NBAS and a sup-plemental motor test based on the Neurological Assessment of the Preterm andFull-Term Newborn Infant (Dubowitz & Dubowitz, 1981).

The results indicated that the full-term control group performed significantlybetter than either of the preterm groups on the motor performance cluster of theNBAS, and the preterm control group performed better than other groups on theautonomic regulation cluster. On the supplemental motor test assessment of pos-tural control, the preterm infants who received NDT treatment outperformed bothcontrol groups on spontaneous behavior items and the preterm control group onelicited activity items.

This study has not been replicated and there are no published randomizedcontrolled trials with a larger sample size that have reported statistically significantlong-term outcomes supporting use of NDT as a primary intervention program inthe NICU. A replication, however, is under way in a large clinical trial in Norway(http://www2.uit.no/ikbViewer/page/publikum/prosjekter/prosjekt?p documentid=216556).

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RESEARCH ON MOTOR INTERVENTION IN NICU

In a review of published intervention studies among infants and toddlers at risk fordevelopmental delay, 17 studies were identified that occurred within a NICU set-ting (Blauw-Hospers & Hadders-Algra, 2005). The content of these programs wasdescribed as including combinations of auditory, tactile, visual, and/or vestibularstimulation as well as calming or stress reduction measures and passive handling.Ten of the NICU intervention studies provided no evidence of positive or nega-tive effect on motor development while seven of the studies primarily implement-ing NIDCAP interventions did support at least short-term positive effects on in-fant motor development. Two of the intervention programs occurring followingNICU discharge that documented significantly greater motor skill improvementthan their control groups provided descriptions of developmental programs andparent involvement in the movement play (Barrera, Cunningham, & Rosenbaum,1986; Lekskulchai & Cole, 2001). Blauw-Hospers and Hadders-Algra (2005) con-cluded that substantial evidence supported the benefits of developmental traininginterventions after NICU discharge in which parents learned how to assist and en-courage their infant’s motor development. They also concluded that programs lim-ited to passive handling techniques were not beneficial while those programs thatwere focused on specific tasks and stimulated infants to actively explore use of theemerging movement skill can have a positive influence.

There is evidence supporting the benefits of movement training during the earlymonths of postnatal life but none supporting this degree of handling and stimula-tion while infants are in the NICU. Among both maturing full term and preterminfants, these initial anti-gravity movements can increase in complexity, frequency,and duration following specific daily training protocols (Heathcock & Galloway,2009; Heathcock et al., 2008). In the home setting, following eight-week, caregiver-based daily training programs, infants with initially two months CA increased theaccuracy, frequency, and duration of reaching as well as hand or foot contact withan object. By four months CA, the prematurely born infants participating in thetraining programs performed more optimally than those prematurely born infantsnot receiving training. In comparison with full-term infants at four months, the in-fants who participated in the training programs demonstrated equivalent skill forseveral movement characteristics.

Although neither of these studies (Heathcock & Galloway, 2009; Heathcocket al., 2008) was conducted in the NICU setting or with infants less than two monthsCA, the content of the movement training provides some helpful guidance to ther-apists teaching parents how to encourage their infant’s engagement in antigravitymovement leading up to and following hospital discharge. The movement trainingprograms focused on task-specific activities provided by parents. The activities in-volved the active participation of the infant in multimodal, interactive tasks. Theseinteractive tasks were not only encouraged during the 10-min daily training ses-sions, but were also likely to be repeated during routine care and play many othertimes during each day as the infant’s responses improved. A good resource sum-marizing the available Cochrane Reviews on the evidence on effects of a variety ofinterventions is the chapter on the “Special Care Nursery” in Physical Therapy forChildren, 4th ed. (Kahn-D’Angelo, Blanchard, & McManus, 2012).

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Because there is a paucity of evidence on exercise programs in the NICU, clini-cians are advised to remain current on the scientific literature in order to identify themost effective interventions to promote motor development in the NICU. Mean-while, the evidence from the large clinical trial by Lekskulchai and Cole (2001)and the movement training protocols designed by Heathcock et al. (2008; see also,Heathcock & Galloway, 2009) provide evidence for recommending home exercisefollowing hospital discharge.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible forthe content and writing of this article.

ABOUT THE AUTHORS

Eilish M. Byrne, PT, DSc, PCS, is the Professional Development, Education andResearch Specialist for the Department of Rehabilitation Services working in theNeonatal Intensive Care Unit at Lucile Packard Children’s Hospital, Palo Alto, CA.June Garber, PT, MACT, is a Senior Physical Therapist working in the NeonatalSpecial Care Nurseries at Emory University Hospital Midtown and Grady Memo-rial Hospital as well as Professor Emerita at Emory University, School of MedicineDivision of Physical Therapy, Atlanta, GA.

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