Neonatal Physiotherapy Assessment

Original Editor - Robin Tacchetti based on the course by Krista Eskay
Top Contributors - Robin Tacchetti and Jess Bell

Introduction[edit | edit source]

Physiotherapists working in neonatal intensive care units (NICU) are an important part of the interdisciplinary team that supports newborns. Communication is an essential part of their role as they regularly interact with other NICU clinicians and family members to determine the baby's needs and implement beneficial interventions.[1] The aim of physiotherapy in the NICU is to promote motor development and bonding in the following ways:[2]

  1. helping the infant bond with their family members
  1. facilitating good developmental skills
  2. offering supportive positioning and handling
  3. improving carryover of therapeutic strategies (i.e. making sure that infants don't only receive therapeutic interventions during a specific physiotherapy session - educating nursing staff / family members helps to ensure carryover of these interventions)[2]

The NICU physiotherapy examination is performed once the infant is medically stable. Physiotherapists collaborate with the medical team to ensure that assessments / interventions occur at the least disruptive time for the infant - i.e. to optimise their sleep.[2]

Subjective Assessment[edit | edit source]

The subjective portion the NICU assessment involves obtaining a thorough history.[2] This information can be collected through discussions with clinicians, family members and a review of the medical chart. The following table details topics that should be included in the subjective portion of the examination and sub-topics within them:

Table 1. Subjective examination topics.[2]
Topics Sub-Topics
Pregnancy history Complications, date of birth, gestational age
Birth history Birth weight, type of birth, complications, Apgar scores
Medical procedures Any procedures performed since birth
Social and environmental history Sleep habits, sleep location, how the infant is feeding, daily routine, positioning and which position they spend the most time in, who takes care of them, siblings
Challenges What challenges does the infant face on a daily basis, what skills are most important to the family? What are the family's strengths?

Objective Assessment[edit | edit source]

Obtaining objective information in the NICU requires a considerable amount of observation in conjunction with standardised tests. The aim of the objective portion of the assessment is to identify an infant's activity and participation limitations and challenges. Participation in the NICU setting might consider tasks such as the infant's ability to:[2]

  • appropriately communicate
  • be held by / interact with parents
  • feed
  • sleep
  • grow

Observation[edit | edit source]

Infants in the NICU are typically medically fragile and will not tolerate long interventions. Thus, objective information is primarily gained through observation. Observing the newborn and their interaction with their environment is called neurobehavioural observation. The following table highlights which areas to observe when performing a neonatal assessment:

Table 2. Areas to observe in the objective examination.[2]
Areas to Observe Noteworthy / Significant Features Within These Areas
Tone Hypotonic, moving limbs against gravity, tight vs stiff, is there clonus?
Physiologic flexion Can they get into and / or stay in physiologic flexion
Vitals Heart rate, respiratory rate, skin colour, changes in vitals from interventions or stressors
Reflexes Infant reflexes; do they get stuck in a reflex position (ATNR)?
Range of motion Active and passive range of motion of various joints
Developmental positions Checking various positions at different times; are there changes in tone in different positions? Do they tolerate a change in position? Look at posture in different positions
Quality of movement Smooth vs rigid, frequent vs sparse movement
Symmetry of movement Symmetrical movement, does one side move more than the other? Are they able to smoothly alternate movements between their upper and lower extremities?
Head shape Plagiocephaly (flat), scaphocephaly (long and narrow), brachycephaly (wide and flat)
Self-regulation Transition through behavioural states, can they maintain a calm, alert, awake state?
Reactions to stimuli Auditory, visual, touch, pain* (NICU infants are more sensitive to pain and have a difficult time modulating pain)

Standardised Tests[edit | edit source]

Neonatal Behavioral Assessment Scale (NBAS)[edit | edit source]

The Neonatal Behavioral Assessment Scale (NBAS) is the most comprehensive neurobehavioural assessment for infants from 35 weeks gestation to 2 months old. The NBAS proposes that infants are social beings communicating through behaviour in a non-random fashion.[3] The scale assesses 53 items within the following categories:[3]

  • habituation (sleep protection)
  • social interactive responses and capabilities
  • motor system
  • state organisation and regulation
  • autonomic system
  • reflexes

** Please note, the NBAS takes a significant amount of time and training to administer, which limits its accessibility and practicality.[4]

Newborn Behavioral Observation System (NBO)[edit | edit source]

The Newborn Behavioral Observation System (NBO) is a shorter instrument designed to capture newborn behaviour and communication cues. The NBO is administered by NBO-trained healthcare practitioners and consists of 18 items that describe an infant's visual, auditory, perceptual and self-regulatory abilities. The family-centred NBO aims to promote a positive parent-infant relationship by increasing parental competence and confidence.[5][4]

Test of Infant Motor Performance[edit | edit source]

The Test of Infant Motor Performance (TIMP) is a video-based instrument used on infants aged 34 weeks gestational age-4 months post-term.[2] This measure is divided into two sections (elicited and observed) and has 59 items in total. The elicited section items assess "motor responses to placement in various positions and to visual or auditory stimulation".[6] The observed section items allow the assessor to rate an infant's spontaneous movements.[6][2]

General Movement Assessment (GMA)[edit | edit source]

The General Movement Assessment (GMA) assesses spontaneous movement of an alert, awake infant in supine. The infant is videoed for 3-5 minutes or is observed directly.[7][8] The GMA is suitable for infants aged 0-20 weeks,[2] and it is widely accepted by caregivers from various cultural and social backgrounds due to its non-intrusive nature.[8] It is suitable for daily clinical application because it is easier to perform than many other neurological tools.[8]

Alberta Infant Motor Scale (AIMS)[edit | edit source]

The Alberta Infant Motor Scale (AIMS) is used for evaluating quantitative and qualitative motor development for infants 0-18 months.[9] The focus of the AIMS is to observe the infant as they move into and out of prone, supine, sitting and standing. The items in the AIMS focus on elements such as antigravity movements, postural alignment and weight bearing that "contribute to motor skills".[10] This scale can be used in inpatient or outpatient settings.[2]

Peabody Developmental Motor Scales[edit | edit source]

The Peabody Developmental Motor Scales-Second Edition (PDMS-2) is a reliable and valid tool originally designed to detect developmental delay in children aged from birth-5 years.[11] [12] This instrument assesses fine and gross motor skills, and identifies motor deficits. It can also assess a child's eligibility for interventions.[12]

Bayley Scales of Infant and Toddler Development[edit | edit source]

The Bayley Scales of Infant and Toddler Development evaluates a child's development compared to the standardised norm.[13] [14] This tool can be used for infants and children aged 1-42 months and helps diagnose developmental delay.[13][14] This instrument assesses an infant's development across five domains:[15]

  1. cognition
  2. language
  3. motor
  4. social-emotional
  5. adaptive behaviour

Resources[edit | edit source]

References[edit | edit source]

  1. Doğan, İ.E., Balcı, N.Ç. and Gündüz, A.G., 2022. Physiotherapy and Rehabilitation Approaches to Premature Infants in Neonatal Intensive Care Units. Journal of Physical Medicine Rehabilitation Studies & Reports. 2022.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Eskay, K. Infant Assessment and Intervention. Plus. 2023
  3. 3.0 3.1 Brazelton Centre UK: Neonatal Behavioural Assessment Scale. 2023. Available from:
  4. 4.0 4.1 Congdon JL, Nugent JK, McManus BM, Coccia M, Bush NR. A Pilot Validation Study of the Newborn Behavioral Observations System: Associations with Salivary Cortisol and Temperament. Journal of developmental and behavioral pediatrics: JDBP. 2020 Dec;41(9):716.
  5. Høifødt, R.S., Nordahl, D., Landsem, I.P., Csifcsák, G., Bohne, A., Pfuhl, G., Rognmo, K., Braarud, H.C., Goksøyr, A., Moe, V. and Slinning, K., 2020. Newborn behavioral observation, maternal stress, depressive symptoms and the mother-infant relationship: results from the northern babies longitudinal study (NorBaby). BMC psychiatry, 20(1), pp.1-14.
  6. 6.0 6.1 Flegel J, HA Kolobe T. Predictive validity of the Test of Infant Motor Performance as measured by the Bruininks-Oseretsky Test of Motor Proficiency at school age. Physical Therapy. 2002 Aug 1;82(8):762-71.
  7. Fontana C, Ottaviani V, Veneroni C, Sforza SE, Pesenti N, Mosca F, Picciolini O, Fumagalli M, Dellacà RL. An Automated Approach for General Movement Assessment: A Pilot Study. Frontiers in pediatrics. 2021:868.
  8. 8.0 8.1 8.2 Silva N, Zhang D, Kulvicius T, Gail A, Barreiros C, Lindstaedt S, Kraft M, Bölte S, Poustka L, Nielsen-Saines K, Wörgötter F. The future of General Movement Assessment: The role of computer vision and machine learning–A scoping review. Research in developmental disabilities. 2021 Mar 1;110:103854.
  9. Eliks M, Gajewska E. The Alberta Infant Motor Scale: A tool for the assessment of motor aspects of neurodevelopment in infancy and early childhood. Frontiers in Neurology. 2022;13.
  10. Jeng SF, Yau KI, Chen LC, Hsiao SF. Alberta infant motor scale: reliability and validity when used on preterm infants in Taiwan. Physical therapy. 2000 Feb 1;80(2):168-78.
  11. Rebelo M, Serrano J, Duarte-Mendes P, Monteiro D, Paulo R, Marinho DA. Evaluation of the Psychometric Properties of the Portuguese Peabody Developmental Motor Scales-: A Study with Children Aged 12 to 48 Months. Children. 2021 Nov 13;8(11):1049.
  12. 12.0 12.1 Valentini NC, Zanella LW. Peabody Developmental Motor Scales-2: The Use of Rasch Analysis to Examine the Model Unidimensionality, Motor Function, and Item Difficulty. Frontiers in Pediatrics. 2022 Apr 20;10:852732-.
  13. 13.0 13.1 Ballot, D.E., Ramdin, T., Rakotsoane, D., Agaba, F., Davies, V.A., Chirwa, T. and Cooper, P.A., 2017. Use of the Bayley scales of infant and toddler development, to assess developmental outcome in infants and young children in an urban setting in South Africa. International Scholarly Research Notices, 2017.
  14. 14.0 14.1 Balasundaram P. Bayley scales of infant and toddler development.[Updated 2021 Nov 24]. StatPearls [Internet]. StatPearls Publishing. 2022.
  15. Balasundaram P. Bayley scales of infant and toddler development.[Updated 2021 Nov 24]. StatPearls [Internet]. StatPearls Publishing. 2022.