Case presentation

Patient information

A preterm male infant, born at 34 weeks gestational age with a birth weight of 1.82 kg, was admitted to the NICU following delivery. The infant was the first child of a 26-year-old primigravida mother with an uneventful antenatal period. The infant was hemodynamically stable, did not require mechanical ventilation, and fulfilled criteria for KMC initiation. There was no family history of chromosomal abnormalities or neurological disorders. Parents' consent was obtained, and the infant was enrolled in the physiotherapy intervention program on Day 1 of admission to the NICU.

Clinical findings

Initial Assessment

Infant alert with stable vital signs. Neurobehavioral evaluation was done on Day 0 as a baseline. Poor repertoire general movement was detected with Prechtl's GMA during the writhing phase in spontaneous motor activity, showing suboptimal quality of spontaneous motor activity. The primitive reflex domains assessed by NBAS showed a baseline score of 1 (present/partial) for all reflex domains except for the domain of nystagmus, which was scored as 0 (absent), similar to normal at this gestational age. Lower limbs bilaterally are hypotonic for muscle tone. No prominent deformities, significant malformations, or active infections were detected. Muscle tone was assessed clinically by the primary investigator, under faculty supervision, through observation of resting limb posture and resistance to passive movement. A formal cranial nerve examination was not performed as a discrete component of this assessment; however, sucking, rooting, and glabella reflexes were evaluated as part of the NBAS primitive reflex battery. No other focal neurological deficits were noted on general observation.

Table 1 presents the chronological timeline of the infant's clinical course and the physiotherapy intervention period.

Event | Date/Duration
Gestational age at birth | 34 weeks
Birth weight | 1.82 kg
NICU admission | Day 0
KMC initiation | Day 1 post-admission
Physiotherapy intervention started | Day 1 of KMC
Duration of physiotherapy intervention | 7 days
Pre-intervention assessment (GMA and NBAS) | Day 0
Post-intervention assessment (GMA and NBAS) | Day 7

Diagnostic Assessment

Baseline NBAS assessment of primitive reflexes was conducted on Day 0. Thirteen reflex domains were assessed on a 0-2 ordinal scale (0 = absent; 1 = present/partial; 2 = fully elicited). The infant scored 1 in all domains except nystagmus (score: 0), which is developmentally expected at 34 weeks corrected gestational age. GMA video observation on Day 0 classified the infant's spontaneous movements as poor repertoire during the writhing phase, indicating reduced variation, speed, and amplitude in global movement patterns.

Table 2 presents the baseline and post-intervention NBAS reflex scores, demonstrating the pre-to-post change across all 13 domains.

Reflex Domain | Pre-Intervention (Day 0) | Post-Intervention (Day 7) | Change
Ankle Clonus | 1 | 2 | ↑ +1
Sucking | 1 | 2 | ↑ +1
Glabella | 1 | 2 | ↑ +1
Plantar Reflex — Legs | 1 | 2 | ↑ +1
Plantar Reflex — Arms | 1 | 2 | ↑ +1
Placing | 1 | 2 | ↑ +1
Standing | 1 | 1 | No change
Crawling | 1 | 2 | ↑ +1
Incurvation | 1 | 2 | ↑ +1
Tonic Head/Eye | 1 | 2 | ↑ +1
Nystagmus | 0 | 0 | No change
ATNR | 1 | 2 | ↑ +1
Moro | 1 | 2 | ↑ +1

Intervention

Rehabilitation Course

A structured seven-day physiotherapy protocol was administered daily during KMC sessions by the primary investigator, under faculty supervision, as detailed below. All sessions were conducted while the infant remained in SSC with the mother. Continuous monitoring of infant stress cues, including color change, bradycardia, desaturation, and behavioral state, was performed throughout. Each session lasted approximately 20-30 minutes.

The intervention was administered by the primary investigator, a postgraduate trainee in Pediatric Neurosciences Physiotherapy, under the direct supervision of a senior faculty member holding a doctoral degree with extensive clinical experience in neonatal neurodevelopmental care. Session standardization was maintained by following the fixed seven-day, phase-wise protocol outlined in Table 3, with each day's session restricted to the designated focus area to ensure consistency in technique and sequence across sessions. Within each 20-30 minute session, time was allocated to infant state observation and settling, delivery of the day's primary therapeutic component, and continuous monitoring for stress cues, with sessions modified or shortened in response to any signs of infant distress. The protocol followed FITT principles: Frequency: once daily; Intensity: graded and cue-based; Time: 20-30 minutes per session; Type: progressive, goal-oriented physiotherapy. Table 3 outlines the week-wise, goal-oriented physiotherapy protocol implemented during the 7-day intervention period.

Day(s) | Focus Area | Therapeutic Interventions | Primary Goals
Days 1–2 | Containment and Tactile Input | Hand placement on shoulders and hips; light touch; slow stroking of limbs | Promote flexed posture; activate C-tactile fibers for calming and sensory integration
Days 3–4 | Kinesthetic Stimulation | Passive range of motion (PROM) for all extremities (5–10 repetitions); slow, graded joint movements | Maintain joint flexibility; provide kinesthetic input during skin-to-skin contact
Days 5–6 | Postural Alignment | Prone-on-chest positioning; flexed supine positioning using towel rolls | Improve head control; promote body symmetry; counteract prolonged supine posturing
Day 7 | Caregiver Empowerment | Education on feeding and sleep positioning; rocking techniques; tactile stimulation training for parents | Transition to family-centered care; ensure sustainable developmental support after NICU discharge

Results

After the seven-day physiotherapy treatment given during KMC, clinically meaningful improvement was observed in both neurobehavioral scores.

General Movements Assessment

Prechtl's GMA determined that the infant's spontaneous movements were ooor repertoire on Day 0 in the writhing phase. A post-assessment on Day 7 after seven days of physiotherapy showed improved quality of general movements, with greater variability, speed, and amplitude within the writhing repertoire, suggesting a clinically meaningful improvement in spontaneous motor activity. As the infant had not yet reached the postmenstrual age at which fidgety movements are expected to emerge (9-20 weeks post-term), true fidgety movements were not anticipated at this assessment; the observed change reflects a qualitative improvement within the writhing phase rather than a transition to the fidgety period. Table 4 summarizes the GMA outcome.

Assessment Timepoint | GMA Classification | Outcome
Pre-intervention (Day 0) | Poor Repertoire (Writhing Phase) | —
Post-intervention (Day 7) | Improved Writhing Movements (increased variability/complexity) | Improved

Neonatal Behavioral Assessment Scale

The infant obtained a score of 1 on each of the 13 NBAS reflex domains at the baseline (Day 0) except nystagmus (score: 0). After the seven-day physiotherapy intervention, the infant's score was improved in 10/13 domains, to a score of 2 (fully elicited). There was no change in standing or nystagmus, as is expected at the current gestation. No deterioration was seen in any domain. Improvements in Moro, ankle clonus, sucking, plantar, placing, crawling, incurvation, tonic head/eye, glabella, and ATNR reflexes indicate better organization of neurobehaviors after physiotherapy and combined KMC. No bradycardia, desaturation, or color change was noted throughout the seven-day intervention period.