Neonatal Physiotherapy Intervention

Introduction

Preterm infants requiring the neonatal intensive care unit (NICU) are a particularly vulnerable population secondary to potential adverse neurological sequeale.The last trimester of pregnancy is associated with rapid brain development and neuroplastic change. This time period coincides with when most infants are in the NICU between 22-40 weeks of gestation. Preterm birth may disrupt genetically programmed patterns of brain development which can lead to neurodevelopmental impairments such as motor dysfunction and behavioural and cognitive problems. Exposure to sensory overload in the NICU (monitors, lights, position changes, multiple episodes of handling) and sensory deprivation of the mothers heartbeat and voice may negatively affect brain maturation.. Limiting these negative neuroplastic changes through calming strategies and movements to stimulate the interuterine environment is the aim of physiotherapy in this NICU.

Neonatal Interventions

There is evidence that supports that early intervention through may alter neuroplasticity and reorganisation of the brain in preterm infants. Interventions within the NICU are individualised and highly specialised with the goal of promoting infant-family bond, long-term developmental domains and preventing adverse sequelae. The theory behind providing neonatal therapy is three-fold:

1. protect the neonatal brain
2. optimise the environment
3. support the family

Implementing parent engagement into the interventions has been shown to have significant and lasting effects on behavioural and cognitive outcomes in infants. A secondary benefit is parents have decreased anxiety and increased confidence when they are involved in interventions.

Neuromuscular

Neuromuscular physiotherapy can include a host of interventions that promote movement and communciation between nerve and muscle.

ROM[

it, passive normal range of motion exercises are performed by the physiotherapist [19]. It is known that normal range of motion exercises applied to the extremities, especially to the proximal joints of the baby, are generally beneficial for bone development Citation: İlknur Ezgi Doğan, Nilay Çömük Balcı, Arzu Güçlü Gündüz (2022) Physiotherapy and Rehabilitation Approaches to Premature Infants in Neonatal Intensive Care Units. Journal of Physical Medicine Rehabilitation Studies & Reports. SRC/JPMRS/168. DOI: doi.org/10.47363/JPMRS/2022(4)150 J PhyMed Rehab Stud Rep, 2022 Volume 4(2): 3-5 [23]. In addition, studies in the literature have shown that range of motion exercises contribute to bone development in various amounts; it is stated that it supports bone mineral density and provides a slight and temporary increase in weight gain and bone mineral density of premature babies [24].

Positioning

Positioning facilitates the organization of posture and movement by supporting the musculoskeletal alignment of the premature baby against gravity with the nesting method. Positioning is an effective method not only for the musculoskeletal aspect of the baby, but also for supporting respiratory functions and providing skin care y, allowing the baby to sleep peacefully for a longer time [25]. In addition, it is stated in the literature that premature babies who stay in the neonatal intensive care unit for a long time and who are not properly positioned have a risk of torticollis, positional plagiocephaly, decrease in the spontaneous movements and quality of movement of the baby, and disorder in the lower extremity joint alignment

Massage

When the extrauterine life is started, the baby continues to experience the sense of touch along with the gravity effect and all other sensory stimuli. Infant massage is one of the early intervention approaches where the baby can systematically receive information about touch in his extrauterine life [28]. Different forms of tactile sense, such as tactile kinesthetic movements, speaking or eye contact can be added to infant massage, which is often applied to the baby’s body parts with stroking movements in the form of gentle and slow hand contact [29]. In the systematic review in the literature, it is stated that massage is effective in the weight gain, growth and development of premature and low birth weight babies and reduces the length of stay in the hospita

NonNutritive Sucking

Sucking Swallow Facilitation Nutrition, which has an important place in the growth and development of the premature baby, is a functional activity with high priority in the newborn intensive care unit, which should be supported by the newborn physiotherapist and other caregivers. Sucking activity is supported by the non-nutritive sucking approach, in which a pacifier or a glove-wearing finger is placed in the mouth in order to provide tactile stimulation to the facial muscles and intraoral structures [16]. In addition, positioning the baby in a raised position with the head in semiflexion during feeding and supporting the baby’s cheeks from the outside are also approaches used in sucking and swallowing facilitation [23]. In a study in the literature, it is stated that the duration of hospital stay of the premature baby is reduced, feeding behaviors are improved, and impulsive and defensive behaviors are reduced during and after feeding, thanks to non-nutritive sucking with a pacifier before and after feeding with a catheter and bottl

kangaroo care

Kangaroo care, also called skin-to-skin contact, is a frequently preferred approach in the neonatal intensive care unit, both as a neuroprotective approach and in terms of mother-infant bonding. Direct mother-infant skin contact is ensured by removing the baby’s clothes and laying the baby in a prone position on his mother’s chest with only the diaper. It is stated in the literature that kangaroo care, which is described as “the newborn’s normal environment”, provides the right environment for DNA, epigenesis, neural networks and physiological regulations to function optimally [31]. It is stated that skin-to-skin contact with the mother or father has a direct neuroprotective feature by supporting brain plasticity [32]. In a study, it was determined

family education

Family education is provided for the behavioral organization, movement and postural development of the premature baby, maintaining its physiological stability, supporting parentinfant attachment, as well as the emotional situation and stress management of the family with the premature baby. For this purpose, for the family to care for the baby; activities such as feeding, dressing, sleep positioning, playing and communicating, and training, verbal information, video narration, written sources and practical methods on strategies that support the baby’s motor movement organization and therapeutic holding and carrying methods [1

environment

]. With environmental regulations such as lighting, sound level adjustment, and ambient temperature to be made for this situation, it is possible to increase the baby’s ability to calm himself, to provide physiological stability and to increase the sleep time. In the neonatal intensive care unit, attention is paid to the following in the regulation of the light level; except for the procedures, the incubator area where the baby is should not be directly illuminated, in order to reduce the direct exposure to light, arrangements should be made to cover the incubator with the help of an incubator cover, blanket or cover. and back, protective equipment such as eye masks should be used for babies who need phototherapy. In addition, care should be taken to keep the ambient lighting at low settings at night, taking into account the night/day cycle of the baby’s sleep-wake times [34]. In order to adjust the sound arrangements and prevent noise in the neonatal intensive care unit, health professionals who make up the neonatal team should be trained on the subject. It should be known that the ideal sound level of the environment where the babies are located should not be higher than 50 dB, the sound level of the devices used should not exceed 40 dB, and the sound increase should not exceed 70 dB temporarily [34]. While the ideal room temperature of the neonatal intensive care unit is set in the range of 21-24 °C, incubator temperature and humidity settings should be followed with various arrangements according to the gestational week of the baby, birth weight, and ability to provide physiological stability. While ideal incubator temperature values are set at an average of 32.4± 1.5 to 35.0± 0.5 °C in the first 24 hours postnatally, it is adjusted between 33.5±0.5 and 32.0± 1.5 °C between 5-14 days. While the humidity in the incubator is set at around 70% in the first 7 days postnatally, it can be reduced to 40% according to the baby’s ability to organize body temperature, and it can be stopped after 21 days depending on the baby’s ability to maintain body temperature [35].

Positioning

Exposure to prolonged atypical posi-

tioning in the NICU has been associated with torticollis, po-

sitional plagiocephaly, reduced movement quality, and lower

extremity malalignment.59,61–63 Developmentally supportive

positioning may enhance the development of normal skeletal

alignment and provide opportunities for normal movement

patterns. Therapists can play a vital role in program develop-

ment and consultation relating to positioni

Sounds

while the NICU environment consists of multiple high frequency noises that exceeding recommended value.may occur by simply opening or closing incubator doors or by the conversation between staff members (DePaul and Chambers, 1995; Marik et al., 2012; Philbin et al., 2017). Assume that these high sound levels may contribute to hearing damage or even hearing loss as diagnosed in 2–10% of preterm infants vs 0.1% of the general pediatric population

The sound environment in the NICU is louder than most home or office environments and contains disturbing noises of short duration and at irregular intervals. There are competing sound signals that frequently challenge preterm infants, staff, and parents

Lighting

here is increasing evidence that introducing robust light-dark cycles in the Neonatal Intensive Care Unit has beneficial effects on clinical outcomes in preterm infants, such as weight gain and hospitalization time, compared to infants exposed to constant light or constant near-darkness.

Environemtal

Multimodal sensory stimulation. Because infants born

preterm are exposed to excessive overhead light, loud

noises, and noxious procedures in intensive care environ-

ments, techniques to limit the consequences of negative stim-

uli are often included in developmental care plans,51 and pro-

vision of positive sensory experiences (tactile, vestibular,

auditory, and visual) has been encouraged in some settin

Neuromuscular

Neuromuscular physiotherapy applications include normal joint range of motion exercises, positioning, therapeutic grips, infant massage, taping, soft tissue mobilization for post-surgical scar tissue, facilitation of sucking and swallowing, kangaroo care practice, and family education

ROM[

it, passive normal range of motion exercises are performed by the physiotherapist [19]. It is known that normal range of motion exercises applied to the extremities, especially to the proximal joints of the baby, are generally beneficial for bone development Citation: İlknur Ezgi Doğan, Nilay Çömük Balcı, Arzu Güçlü Gündüz (2022) Physiotherapy and Rehabilitation Approaches to Premature Infants in Neonatal Intensive Care Units. Journal of Physical Medicine Rehabilitation Studies & Reports. SRC/JPMRS/168. DOI: doi.org/10.47363/JPMRS/2022(4)150 J PhyMed Rehab Stud Rep, 2022 Volume 4(2): 3-5 [23]. In addition, studies in the literature have shown that range of motion exercises contribute to bone development in various amounts; it is stated that it supports bone mineral density and provides a slight and temporary increase in weight gain and bone mineral density of premature babies [24].

Positioning

Positioning facilitates the organization of posture and movement by supporting the musculoskeletal alignment of the premature baby against gravity with the nesting method. Positioning is an effective method not only for the musculoskeletal aspect of the baby, but also for supporting respiratory functions and providing skin care y, allowing the baby to sleep peacefully for a longer time [25]. In addition, it is stated in the literature that premature babies who stay in the neonatal intensive care unit for a long time and who are not properly positioned have a risk of torticollis, positional plagiocephaly, decrease in the spontaneous movements and quality of movement of the baby, and disorder in the lower extremity joint alignment

Massage

When the extrauterine life is started, the baby continues to experience the sense of touch along with the gravity effect and all other sensory stimuli. Infant massage is one of the early intervention approaches where the baby can systematically receive information about touch in his extrauterine life [28]. Different forms of tactile sense, such as tactile kinesthetic movements, speaking or eye contact can be added to infant massage, which is often applied to the baby’s body parts with stroking movements in the form of gentle and slow hand contact [29]. In the systematic review in the literature, it is stated that massage is effective in the weight gain, growth and development of premature and low birth weight babies and reduces the length of stay in the hospita

NonNutritive Sucking

Sucking Swallow Facilitation Nutrition, which has an important place in the growth and development of the premature baby, is a functional activity with high priority in the newborn intensive care unit, which should be supported by the newborn physiotherapist and other caregivers. Sucking activity is supported by the non-nutritive sucking approach, in which a pacifier or a glove-wearing finger is placed in the mouth in order to provide tactile stimulation to the facial muscles and intraoral structures [16]. In addition, positioning the baby in a raised position with the head in semiflexion during feeding and supporting the baby’s cheeks from the outside are also approaches used in sucking and swallowing facilitation [23]. In a study in the literature, it is stated that the duration of hospital stay of the premature baby is reduced, feeding behaviors are improved, and impulsive and defensive behaviors are reduced during and after feeding, thanks to non-nutritive sucking with a pacifier before and after feeding with a catheter and bottl

kangaroo care

Kangaroo care, also called skin-to-skin contact, is a frequently preferred approach in the neonatal intensive care unit, both as a neuroprotective approach and in terms of mother-infant bonding. Direct mother-infant skin contact is ensured by removing the baby’s clothes and laying the baby in a prone position on his mother’s chest with only the diaper. It is stated in the literature that kangaroo care, which is described as “the newborn’s normal environment”, provides the right environment for DNA, epigenesis, neural networks and physiological regulations to function optimally [31]. It is stated that skin-to-skin contact with the mother or father has a direct neuroprotective feature by supporting brain plasticity [32]. In a study, it was determined

family education

Family education is provided for the behavioral organization, movement and postural development of the premature baby, maintaining its physiological stability, supporting parentinfant attachment, as well as the emotional situation and stress management of the family with the premature baby. For this purpose, for the family to care for the baby; activities such as feeding, dressing, sleep positioning, playing and communicating, and training, verbal information, video narration, written sources and practical methods on strategies that support the baby’s motor movement organization and therapeutic holding and carrying methods [1

environment

]. With environmental regulations such as lighting, sound level adjustment, and ambient temperature to be made for this situation, it is possible to increase the baby’s ability to calm himself, to provide physiological stability and to increase the sleep time. In the neonatal intensive care unit, attention is paid to the following in the regulation of the light level; except for the procedures, the incubator area where the baby is should not be directly illuminated, in order to reduce the direct exposure to light, arrangements should be made to cover the incubator with the help of an incubator cover, blanket or cover. and back, protective equipment such as eye masks should be used for babies who need phototherapy. In addition, care should be taken to keep the ambient lighting at low settings at night, taking into account the night/day cycle of the baby’s sleep-wake times [34]. In order to adjust the sound arrangements and prevent noise in the neonatal intensive care unit, health professionals who make up the neonatal team should be trained on the subject. It should be known that the ideal sound level of the environment where the babies are located should not be higher than 50 dB, the sound level of the devices used should not exceed 40 dB, and the sound increase should not exceed 70 dB temporarily [34]. While the ideal room temperature of the neonatal intensive care unit is set in the range of 21-24 °C, incubator temperature and humidity settings should be followed with various arrangements according to the gestational week of the baby, birth weight, and ability to provide physiological stability. While ideal incubator temperature values are set at an average of 32.4± 1.5 to 35.0± 0.5 °C in the first 24 hours postnatally, it is adjusted between 33.5±0.5 and 32.0± 1.5 °C between 5-14 days. While the humidity in the incubator is set at around 70% in the first 7 days postnatally, it can be reduced to 40% according to the baby’s ability to organize body temperature, and it can be stopped after 21 days depending on the baby’s ability to maintain body temperature [35].

Music Therapy

It aims at relaxing and nurturing the infant as well as promoting safety and social interaction for the parent-infant dyad. A music therapist specially trained in CMT hums or sings in an infant-directed, improvised, lullaby style continually adjusting to the individual needs, expressions, and breathing pattern of the preterm infant. Based on the principles of family-integrated care, the family is incorporated individually in the therapeutic process, namely by delivering CMT during kangaroo care (KC) and by motivating and facilitating parental vocal interaction with their infant to strengthen the parent-infant bonding. CMT aims at relaxing, stimulating, and coregulating premature infants at a time when many other interventions are still risky and can overwhelm the vulnerable patient group. CMT may be advantageous not by educating and teaching parents, but rather by uncovering the intuitive capacities of parenting that are often overshadowed by the traumatic experience of preterm birth. However, CMT can only be provided when the infants are clinically stable. CMT with parental integration is feasible when parents are available and receptive to participate.

Massage Therapy

The results of this meta-analysis demonstrate that massage therapy significantly increases daily weight gain in preterm neonates, including low birth weight neonates and very low birth weight neonates. In addition, moderate pressure massage therapy versus light pressure massage therapy is found to greater daily weight gain in preterm neonates.

Parent AdministeredTherapy

add resources course- Sweeney JK, Heriza CB, Blanchard Y, Dusing SC. Neonatal physical therapy. Part II: Practice frameworks and evidence-based practice guidelines. Pediatric Physical Therapy. 2010 Apr 1;22(1):2-16.