Discussion

This case report illustrates the feasibility of a structured seven-day physiotherapy program given in the KMC setting and its positive neurodevelopmental outcomes in one LBW preterm baby. The infant improved in 10 of 13 NBAS primitive reflex domains and moved from poor repertoire GM to normal fidgety movements, and no adverse events were reported. The results were in line with and extended the growing evidence base supporting the embedding of neonatal physiotherapy into developmentally appropriate care systems. The secondary structure of C-tactile afferent fibers creates a neurophysiologically beneficial environment for KMC, providing oxytocin and endogenous opioid release and decreased pain sensitivity, which enables autonomic regulation [7]. During KMC, the infant is already in a parasympathetically dominant, hormonally regulated state, which is theorized to facilitate the integration of proprioceptive, vestibular, and kinesthetic inputs to a greater extent than either intervention could achieve alone [3,4]. It should be noted that these neurophysiological mechanisms were not directly measured in the present case and remain theoretical, based on findings from prior literature. The tactile containment and slow-stroking manipulation during Days 1-2 of the protocol are similar to the CT-activating stimuli described by Cascio et al. [11], which have demonstrated calming, neuroregulatory effects and support sensory-motor integration. Passive range of motion was introduced progressively on Days 3-4, which matched the physiotherapy approaches described by Sweeney et al. [12], which suggested cue-based, graduated sensory-motor stimulation based on individual infant readiness. The postural alignment activities on Days 5-6 specifically targeted a common issue of prolonged NICU stay: suboptimal positioning and limited active movement, which can lead to maladaptive posturing, and aimed to help the child achieve midline alignment and head control [8].

Structured tactile-kinesthetic stimulation has been shown to elicit profound changes in motor organization, weight gain, and autonomic stability in preterm infants by Field et al. [9]. Another systematic review by Alvarez et al. also found that the standardized use of massage therapy by trained personnel consistently enhances physiological stability and behavioral organization of hospitalized preterm neonates [13]. In this instance, the enhancement of NBAS reflex scores correlates with these findings and confirms the importance of using structured tactile-kinesthetic input to help facilitate reflex maturation. The change from poor repertoire to an improved, more variable writhing movement pattern seen at GMA is clinically relevant. True fidgety movements typically appear after 9-20 weeks post-term age, and their absence at the expected timepoint strongly predicts cerebral palsy and neurodevelopmental disorder [14]; however, as this infant's post-intervention assessment occurred well before that expected window, fidgety movements were not anticipated, and the observed improvement instead reflects a positive change within the writhing phase itself. While this improvement cannot be solely attributed to the physiotherapy intervention, due to the possibility of spontaneous maturation occurring over the seven-day period, the size and direction of change in GMA and NBAS indicate that the structured approach may have supported and/or accelerated the maturation of the brain system.

Day 7 focuses on the caregiver empowerment component of the family-centered model of care, offering parents opportunities to build the skills to carry on with developmentally supportive activities following their infant's NICU discharge. This is an important shift in order to maintain neurodevelopmental advances in the home environment and is congruent with goal-directed therapeutic approaches outlined by Lowing et al. [15]. It should be noted that due to the one-case design limitations, causal inference cannot be made. It is not possible to differentiate the contribution of KMC alone and physiotherapy alone, spontaneous neurological maturation, and the combination. Long-term follow-up data were not available to determine the longevity of the improvements observed. However, the findings from this case report represent a valuable clinical preliminary finding and template for protocol design for future controlled trials in this population.

Limitations and future directions

The present case report has limitations due to its single-case design, which limits generalizability and precludes causal inference. Due to the lack of a comparison group, it is not possible to determine the independent effects of structured physiotherapy, KMC alone, or spontaneous neurodevelopmental maturation on the outcomes measured. Long-term neurodevelopmental follow-up was not performed; thus, conclusions regarding the sustainability of improvements may be limited. The case report design did not allow for assessor blinding, thus potentially leading to assessment bias. Outcomes may also have been affected by variability in the NICU and the infant's medical condition. As larger study samples, controlled design, blinded assessment, and longer follow-up periods are recommended, future research is warranted in order to draw evidence-based conclusions regarding integrated physiotherapy-KMC treatment protocols for LBW preterm infants. Additionally, NBAS and GMA assessments were performed by a single, non-independently certified assessor under faculty supervision, without blinding to intervention status, which may have introduced assessment bias.