One seat, two seat, red seat, blue seat!

During this time of COVID-19, social distancing, and schools being virtual for the time being, I know parents are struggling with keeping their children on task, engaged with their school work, and not pulling their own hair out of their heads. While as a physical therapist I don’t have all the answers to help with keeping your children on task, within my scope of practice I CAN offer guidance on the importance of flexible seating/standing options for your at home classroom space as well as which options may be the best for you to invest in to help your children thrive.

What is Flexible Seating?

Flexible seating is a concept in the school system which is getting increasing recognition and use in many classrooms. It encourages the idea of allowing children to sit where ever they want - basically getting rid of the “students sit in straight lined desks” idea that WE all grew up with. With this new model of seating also offers students a variety of chair/desk options to chose from as well around the classroom. From balls, to the floor, to a traditional desk, to a standing surface, teachers are attempting to offer “flexible” choices for their students in order to promote learning and engagement and decrease the amount of time spent sedentary.

Why have Flexible Seating?

Research on flexible seating has shown a great many benefit for both the student and the teacher leading the students. The list below attempts to encompass some of the research that has been done on the positive effects:

• Increased focus and engagement

• Increased self of control over environment

• Creates a calm and FUN environment

• Promote small group and large group work easily

• Promotes physical activity and movement throughout the day

  • This increases blood flow and STIMULATES that growing brain!

• Increases sensory input to help children with ADHD, ASD, etc.

• Increased comfort while in a classroom setting

Physical therapy perspective on the benefits of Flexible Seating.

As a physical therapist I LOVE and excitedly promote flexible seating options for my clients (and their parents!) Humans are designed to MOVE not to be sedentary and flexible seating allows the body to find the motion it needs while still being able to attend to a cognitive task. Also, from a PT perspective, flexible seating = core strength and body awareness! These are some of the biggest things I work on with kids who need my services. Whether it is a child with Down Syndrome or a kiddo with Toe walking, I am constantly attempting to increase core strength as well as their perception of where they are in space. Flexible seating options allow them to explore this simultaneously as their brain is being empowered to learn more (WHAT A BETTER TIME TO IMPROVE INCREASED MOTOR FUNCTION?!) Check out some of these other benefits specifically related to physical activity and physical functioning:

• Increased core strength

• Decreased time spent sedentary

  • Decreased risk for cardiovascular/physical fitness decline

  • Decreased risk for childhood obesity

    • Increases calorie burn and metabolism

• Increased balance

• Increased sensory input

  • Could either be excitatory input to rev up the brain

  • Or inhibitory input to help calm and regulate in order to focus

  • the great part is the KID gets to chose what they need at that particular time!

• Better posture

  • Less slouching, surfaces tend to promote more erect posture

Types of Flexible Seating

The following are types of flexible seating options that are commonly used in classrooms and could also be easily used inside of the home. I also included some ways to modify these for items you already have in your home and you didn’t know could be used to help improve your child’s focus! Follow the hyperlinks to see an example and where you can potentially purchase the products listed:

Balls

• Swiss Ball

• Peanut ball

Wobbly seats

• T-stools

• Rounded bottom stools

• Rocker Chair

Floor Seating

• Bean Bag Chairs

• Floor cushion

• Couch Cushions/pillows can be a great alternative to buying something

Standing Desk

• Counter tops or Kitchen table (depending on child’s height) are a great way to modify this if you don’t want to purchase a standing desk

Seating Modifications

• Bouncy Band

  • Do you have old resistance bands around your house?? You can tie these around the legs of a chair to simulate this!

• Foot rocker board

  • You can also stand on this to modify a standing desk!

• Dyna disc/air cushion

  • You can also stand on this to modify a standing desk!

  • Or sit on it on the ground!

Why should I use Flexible Seating in my Home?

If you are struggling to get your kid to concentrate I ask you to take a look at how you are making them sit for their work. Are they seated at the kitchen table on a chair that is too high for them, feet dangling? Are you allowing them to move around the house and work where they feel best?

Now I am not saying that they get to “work” right where all the games and distractions are but likely they haven’t found a new place that works best for them, and as a parent its your job to help guide them as their teacher would have to finding a place that makes them the most comfortable and able to concentrate. Kids are at home for the duration, this is their NEW classroom for at least now. Help them make the most of it!

Likewise, I ask you to ask yourself… what are YOU doing for your seating options? Are you now tele-working for the first time and finding your back hurts? Is your stiff at the end of the day? Are you fidgeting in a chair that is not really comfortable? It might be time to look at flexible seating options for you too! And there are a lot of great options that both you and your kid could benefit from! A rule of thumb I have for my adult clients is to only spend a maximum of 60 minutes in one position. After that time, switch positions or go for a walk if you can take a short break from your work… trust me on this! You’ll feel MUCH better.

And with that…Have fun with your Home-Classroom/Work Space Modifications!

Life is a Balancing Act!

Happy Fall everyone!!! Here is a quick blog post on frequent falling in kids, how to know when they are falling more than they ought to, and some fun ways to work on balance at home!

Photo by Scott Webb from Pexels

But kids fall all the time??

YEP!! They DO! and its a GOOD THING!!! Kids should fall, a lot! They should not be AFRAID of falling. They should honestly look like a rubber bouncy ball when they hit the ground - back up and playing nearly instantly.

Falling works on so many things! It is great vestibular input - it helps the body determine where its center of gravity is and how far outside its base of support they can push it without falling. It works on strength - catching yourself when you fall is not an easy thing! AND it works on confidence in movement - the kid who is OK with falling is probably pretty darn confident in their skill set and knows what might push them outside their comfort zone and TRIES IT ANYWAYS!

So is my kid falling too much?

Likely the answer is no they are not - they are falling a normal amount, which is a lot! However here are some red flags when it comes to falling!

• Are they afraid to fall? Do they actively avoid activities where they could fall?

• Are they tripping themselves with their own feet?

• Are they tripping over objects or thresholds that seem odd to have caught their toe on or not seen? Or are they running into objects and acting as if they couldn’t see them?

• Are they poor at catching themselves when they fall?

If your kiddo is showing some or all of these signs, having a conversation with your pediatrician or pediatric physical therapist is a good idea. It could be indicative of visual issues (near or far sighted), sensory sensitivities (gravitational insecurities), lower extremity alignment issues (in toeing), or difficulties with vestibular input (lack of good protective reactions or postural control)

How can I work on it at home with my kid?

As always, there are some easy ways to work on balance at home with games and other fun tasks. Check out 5 of my favorite ways below!

Half Kneel

This is a great way to work on hip and core strength as well as balance! I typically encourage kids to either play at a wall or low table for those that need a little extra help. Or if they need some challenge make them catch or bounce a ball!

Sidewalk/ Balance Beam

The edge of sidewalks or parking barriers make perfect balance beams for working on! Up the challenge by having your child balance something on their head or balance an egg on a spoon!

Marble Game

One of my favorites that I use all the time in clinic! Set out a bunch of marbles and have your child pick them up with their toes while standing on the other foot and place them in a bucket or other container.

Bucket Walk/Balance Stones

This one you can create if you have your own buckets or get it on amazon! To encourage going back and forth have them work on a puzzle or game which has pieces that need retrieved and taken across!

Propped Single Leg Balance

Have your child place one foot up on a stool or ball and keep their balance on the other! Like half kneeling, this can be done at a wall or table for extra support or challenged with catching a ball!

Hope you got some good ideas for fun balance activities! And if you ever have any questions about how to work on these at home, reach out to your pediatric physical therapist to ask!

Where are your Ninja Skills?!

This blog is all about OBSTACLE COURSES! Dr. McIntyre LOVES obstacles courses during treatment sessions because they work on balance, gross motor skills, coordination, strength, and control! Kids LOVE obstacle courses during sessions because they are fun and engaging. To make an awesome obstacle course all you need is a little imagination…plenty of space (outside or inside)…and the readiness to have A LOT of fun!

Let’s dive into some tried and true ways to create (a not so expensive) obstacle course that will be challenging and rewarding for your family!

This is an example of an obstacle course that Dr. Megan puts together for her clients.

For this course she used a puzzle for an incentive, ramp for balance and strength, balance pods for balance, gym mat to crawl under, half foam roller for a balance beam, hoops to encourage broad jumping, and a BOSU ball for balance to put the puzzle together!

Building Your Own:

First things first - it is an obstacle course which means it needs LOT OF OBSTACLES!!! Pick at least 5 different “tasks” to make sure your course is long enough to be entertaining. Depending on your child’s attention span, you may not want to do more than 10 tasks as this may make the course too long to repeat several times or complete at all. Basically you want your course to be challenging but easy enough they can be successful - this beautiful combination will boost their confidence at the same time as improving their strength, balance, and coordination!

Secondly - Having an “incentive” to complete the course is always a good idea too! Whether it be completing a puzzle one piece at a time, doing it for speed to see who can be fastest, or making a learning course with colors, shapes, vocab or simple math questions after each task (depends on what your child is working on/learning at the time), this can be an added component to increase the FUN of the course and make the activity last for a long time! (always good when it comes to entertaining kids!)

Third - Most courses can be built with materials you ALREADY have at home! Or with Dollar store items so they don’t have to be expensive or lengthy to build! Of course you can get fancy and build obstacles from wood or other materials but if you aren’t handy you can build one just as fun without those things! Just let you imagination rule (or a few ideas from this blog!)

Alright here are some fun ideas and suggestions for your own course:

Balance activity:

Always important for an obstacle course! Here are some ideas for balance activities:

1. Walking across pillows

2. Taping a balance path (can be straight like a beam or zig zag for more fun!)

3. If you have “river stones” or balance pods - make a “don’t touch the floor its lava” scenario!

Carrying something:

A great way to work on hand eye coordination and attention!

1. Egg/spoon race

2. (for outside) carry a water balloon without breaking it through the whole course - then you get to smash it at the end!

3. Bean bag on their head while they walk across a balance beam (works on body awareness too!)

Animal Walks:

A fun way to get their whole body involved and mind working on how to move like a certain animal!

1. Animal walk (crab/bear/kangaroo) from cone to cone or down a hallway

2. Frog hop from pillow to pillow - what noise does a frog make?

3. Have them spell an animal’s name then pretend to be that animal

Sliding:

Because who doesn’t love sliding?

1. Put socks on feet and hands - have to slide down the hallway with hands and feet on the ground with the decreased friction - don’t let your knees elbows or belly touch the ground!

2. Run and slide and see how far they can slide down the hallway - the length dictates a math or vocab question they get!

3. Tradition slide outside if you have a playground you can integrate into your outside obstacle course!

Agility activity:

Quick feet quick feet! Works on coordination, balance, and of course, agility!

1. Pool noodle “tire run” - if you have tires awesome! if you don’t you can make circles out of pool noodles and tape them together

2. Cone weave- run as fast as you can weaving through a line of cones

3. Shuttle Run - have your child run a bean bag from cone to cone in a zig zag motion dropping one bean bag and picking up another before running for the next cone

Throwing/catching/kicking something:

Works on hand-eye coordination, coordination, and is really good for social play

1. Pool noodle javelin - throw a pool noodle like a javelin through a pool noodle bent into a circle

2. Kick a series of balls through goals or targets

3. Make a bean bag catching “stomper” - basically a wedge and a longer board- place a bean bag on one end and they have to stomp on the other to toss the bag in the air and then catch it!

Lights out!

Yep - turn those lights out! Use glow sticks or flashlights to navigate the course!

Crawling:

Works on whole body coordination, strength, and body awareness

1. Army crawl under string/streamer strung between pieces of furniture - don’t touch it! Its electric!

2. Laser course - take string and tie it at various angles throughout a room - they have to crawl under, through, over, sideways, etc without touching the lasers to get to the prize on the other side (think crown jewel heist!)

3. Make a tunnel out of blankets or purchase a play tunnel to crawl through, outside bend noodles in to a U shape and crawl under them

Jumping:

Bounce, bounce, bounce! Addresses strength, balance, and coordination

1. Use pool noodles to set up hurdles - outside use pens to help them stay in a U shape to jump over or inside put the noodle between two stools- change the height of the U to change the challenge or height of the stools

2. Going back to pillows or river rocks - have them jump between them working on jumping further and further!

3. Jumping down or up onto something - off a step or onto the couch - whatever works at your house!

I hope this blog gave you some great ideas for building your own obstacle course at home whether it be inside or outside! Share your obstacle course designs on our Facebook page! I would love to see your creativity!

Developmental Coordination Disorder

For the parents of the “clumsy kids” and the “awkward movers”, Developmental Coordination Disorder (DCD) can be a confusing diagnosis and difficult to understand how it affects your child as well as what can be done to help eliminate negative effects of having it. In this blog, Dr. McIntyre goes over DCD. Hopefully this blog improves your insight on the condition: what it is, how its treated, and how your child can overcome it.

What is Developmental Coordination Disorder?

Developmental Coordination Disorder (DCD) is a condition where children experience delays in motor skills, specifically with coordinated movements, that result in a the child have difficulty with or being unable to perform common every day tasks. It affects 5-6% of school aged children and the effects can persist into adolescents and adulthood. These are typically the children labeled as clumsy or awkward by teachers, parents and peers.

The following listed are the medical criteria for diagnosis with DCD by a medical professional:

A) Learning and execution of coordinated motor skills is below expected level for age, given opportunity for skill learning.

B) Motor skill difficulties significantly interfere with activities of daily living and impact academic/school productivity, prevocational and vocational activities, leisure and play.

C) Onset is in the early developmental period.

D) Motor skill difficulties are not better explained by intellectual delay, visual impairment or other neurological conditions that affect movement.

The delays are typically first noticed when the child is attempting to learn motor patterns that require precision or skill (roughly preschool to early elementary age). Typical early milestones such as sitting unsupported or rolling over are not effected. Skills that are typically affected or delayed:

Kids with DCD will be challenged by games that involve ball skills.

• Self care skills:

  • feeding: using utensils

  • getting dressed: managing a button or zipper

• Whole Body Coordination

  • Where arms and legs are doing different things

  • i.e. Jumping Jacks, skips, galloping

• Hand-eye coordination

  • i.e. catching, throwing, kicking

  • Grading the movement (how far to throw or kick)

  • Timing of the movement (when to catch or kick)

Here are some other signs that indicate an assessment for DCD:

A child with DCD may struggle with writing and school work.

• moves awkwardly

• seems clumsy or poorly coordinated

• frequently trips, or drops things

• prints or writes poorly, and with much effort

• has trouble with daily activities such as handling utensils, catching a ball, cutting with scissors, tying shoelaces

• avoids participation in physical or motor-based activities

• has difficulty learning and transferring new motor skills

While DCD is a condition all in and of itself, it can be associated with other conditions diagnosed in early childhood. Some of these conditions include: ADHD, speech delays, learning delays, and behavioral conditions.

What causes DCD?

There is no known cause of DCD but doctors have some speculations on what is occurring in the brain to cause the symptoms of the condition. Likely it has something to do with the cerebellum which is the brain’s coordination control center. Here are a couple of leading theories:

1. Children with DCD may have difficulty with processing their environment. The nerves of the body receive “input” from the environment which is then sent to the brain. Potentially as the information reaches the brain, the child is having issues with processing this information into a motor output. If the brain processes the information poorly or incorrectly the motor output in response is poorly coordinated, graded, or timed when compared to the original input.

2. Children with DCD have also been shown to have difficulty with postural control and body awareness. These children rely heavily on visual input to known where they are in their environment. This may indicate they struggle with relying on other sources of information to adjust their body position and posture in space.

What makes DCD so Different?

Other motor delays are typically caused by a known underlying pathology - i.e. neurological or genetic condition. In these conditions obtaining new skills can be hard. The child may have strength issues, low tone or high tone etc. However, there is no barrier to the coordination of these skills in terms of processing environment when looked at in a text book manner. Obviously children with other conditions can have some of the same processing issues as children with DCD.

However, in children who have only DCD, there is no clinical loss of strength, typically no tone issues, no visual impairments etc that can be described as a “cause” of their lack of coordination development. DCD can be more of a silent condition unless parents or teachers become concerned about a child’s ability to perform play and self care tasks.

While DCD does seem like a struggle for the child that has it and maybe frustrating for the parent who has to help them with tying their shoes every morning… the negative effects of DCD can run far greater. DCD is imperative to treat early if diagnosed. The following are some of the negative implications of DCD on other realms of development:

• Behavioral difficulties: If you treat early you can avoid behavioral issues with your child as they become more frustrated with their difficulty with simple every day tasks

• Decreased physical activity: Children with DCD tend to have decreased physical activity levels as they avoid the movements they struggle to perform. In the long run this leads to potential obesity and cardiovascular concerns.

• Poor social engagement: Children with DCD may also withdraw from social activities as they feel awkward with attempting to interact with their peers on the playground playing ball or other game. This can lead to decreased social performance and social anxiety over time.

So how do I know if my child has DCD?

After a conversation with your child’s doctor about your concerns you will likely be referred to either physical therapy or occupational therapy. There are several tools used by your physical therapist (or occupational therapist) to determine if your child has DCD or is at risk for a coordination delay.

-Movement Assessment Battery for Children (M-ABC2), Second Edition: A tool used to evaluate your child’s coordination development and look for motor function impairment. It looks at three different categories - manual dexterity, ball skills, and static and dynamic balance. It will categorize your child as typical, at risk, or delayed. It can be used on children 3 to nearly 17 years of age.

-Test of Gross Motor Development (TGMD-2): A tool used to evaluation your child’s gross motor development and coordination. It looks at 2 different categories of movement: Locomotor skills (like running or galloping) and Object Control (like dribbling and catching). It ranks children on a percentile based on normative values. It can be used on children 3-11 years of age.

-Peabody Developmental Motor Scales (PDMS-2): A tool used to evaluation your child’s gross motor and fine motor skills compared to norm referenced values. It looks at 6 different subcategories: Reflexes (for infants), Stationary skills, locomotor skills, object manipulation skills, visual-motor integration skills, and grasping skills. These subcategories can be lumped into two larger categories of gross motor skills and fine motor skills. It can be used on children 0-5 years of age.

All three of these tools can be used to assess your child across a variety of different skills and compare them against age appropriate peer performance. For most therapists, if you child score’s below the 25th percentile they should be monitored and below the 10-15th percentile they should be treated for DCD.

How can I help my child if they have DCD?

Most children with DCD get referred to either (or both) physical therapy and/or occupational therapy. If you get referred by your pediatrician or other MD, I recommend attending your evaluation and getting the opinion of the therapist on whether or not your child will need PT/OT treatment. Research currently shows that physical therapy intervention is effective at treating DCD when compared to complete inaction. (Offor et al). There are several ways to address DCD through therapy:

• Task-oriented intervention: The therapist will work on the specific challenges your child has. They will work on part-task and task break down/slow down as your child builds the ability to coordination whatever they are struggling with.

  • This type of intervention also works on application of the task into other environments and situations in order to make sure your child can take their new movement pattern/skill “on the road” so to speak.

• Assist with problem solving- identification and solution finding: The therapist will help your child reason through their different movement difficulties and help them learn to find solutions to their challenges. The therapist will teach your child tricks and techniques for assisting themselves with challenging tasks.

• Address other impairments: Because your child is not moving in a typical way during play, or maybe not playing as much because the coordination of play with their peers is hard, they are likely not developing the strength and balance appropriate for their age. Your therapist will test and see where your child has deficits in strength, balance, endurance, and core activation and work on these deficits to make sure they are age appropriate. A child cannot perform skipping if they don’t have to the balance or strength to perform a single leg hop.

The biggest thing you can do to help your child is to make sure you get the right help as early as possible. If you suspect Developmental Coordination Disorder, speak with your pediatrician and discuss your concerns. Follow up with any referral you are given and attend therapy if it is recommended. With the right help, your child can overcome DCD and live a full and fulfilling childhood!

Resources:

CanChild: https://www.canchild.ca/en/diagnoses/developmental-coordination-disorder

Pearson: https://www.pearsonassessments.com/

Elon Tests and Measures: https://blogs.elon.edu/ptkids/category/tm-tools/

Offor, N., Ossom Williamson, P., & Caçola, P. (2016). Effectiveness of Interventions for Children With Developmental Coordination Disorder in Physical Therapy Contexts: A Systematic Literature Review and Meta-Analysis. Journal of Motor Learning and Development, 4(2), 169-196.

Pigeon or Duck Walk! Oh My!

Dr. McIntyre often gets referrals for children who either walk with their feet turned in toward one another or turned out away from one another excessively. Often these are normal in the course of pediatric gait development but sometimes can be significant enough to need treatment through physical therapy or be an indication of a greater problem. In this blog Dr. McIntyre will go over pediatric in-toeing and out-toeing, when it is normal, when to seek consultation or treatment for your child, and how its treated in the clinic.

What is in-toeing?

In-toeing or pigeon toed is a gait pattern where a child’s toes point inward toward one another when standing, walking, or running. Generally mild in-toeing is a normal finding in gait development when the child is between 2-5 years of age and typically grows completely out of the presentation by 8 years old at the latest. In-toeing generally does not cause issues if mild, but if excessive, there is the potential for increased fall/injury rate, decreased balance, clumsiness of movement and pain in hips, knees, and feet. Skeletal causes relate to underlying skeletal changes that are typically seen in children and for the most part are part of normal gait development. Non-skeletal causes include muscle imbalances, weakness, and co-morbidities.

Skeletal Causes

Demonstrates all three causes of in-toeing.

• Femoral Antetorsion: internal twisting of the femur (thigh bone) resulting in the rest of the lower extremity turning inward toward each other - sometimes including presentation of knock-kneed (or valgus). We are born with ~ 40d of antetorsion. By the time we reach adolescents, it decreases to 10-15d. In-toeing from femoral antetorsion is seen most typically between ages 2-4. It worsens when running or with fatigue at the end of the day. Femoral antetorsion resolves itself developmentally without intervention ~ 99% of the time. Studies have shown braces, special shoes, etc do not help speed up the position of the femur or change the natural progression of boney development.

• Internal/medial Tibial Torsion: Internal rotation of the tibia (lower leg bone) causing the foot to turn in even though the knees are pointed straight. At birth we have 0-5 degrees of internal torsion of the tibia compared to the fibula. By 2 years old we should have 10-15d of external torsion and by 5 years of age into adulthood we have 23-30d of external torsion. Typically in-toeing from this cause is seen as soon as the child starts walking and may persist to the age of 4. Again, studies show intervention does not change the natural progression of boney development.

• Metatarsus Adductus: a convexity of the lateral (outside) aspect of the foot: i.e. the forefoot curves medially (inward) causing the feet to look turned in even though the rest of the lower extremity alignment is neutral. Thought to be caused by decreased intrauterine space, most children have a flexible metatarsus adductus meaning it is correctible to neutral. 90-95% of children reduce their presentation naturally and their feet straighten out without intervention. In some cases a straight lass shoe (no curve in the shoe) can be worn to help promote the neutral alignment of the feet.

Non-skeletal causes:

• Hip and core weakness: lack of good hip control can lead to the whole leg turning in and the in-toe presentation. Children may also toe-in to help stabilize their standing posture if their core is weak- using their ligaments and skeletal system to stay in an upright posture. Potentially may also be related to children who have lower tone from a genetic condition or other developmental issue.

• Flat feet: the collapse of your child’s arch causes an internal rotation moment from the ground up on their lower extremity. This may lead to in-toeing presentation as a compensation for their flat feet.

• Neurologic conditions: Children with spasticity may present with in-toeing from spastic medial (inside) leg muscles.

What is out-toeing?

Out-toeing or duck walking is a gait presentation where a child’s toes point excessively away from one another. Having 4-10 degrees of out-toeing is a normal presentation for all ages during walking especially into adolescents and adulthood. While excessive out-toeing is typically not an issue, sometimes it can cause increased stress on the hip, knee, and ankle and potentially lead to pain or difficult with dynamic activities like running and jumping. Causes are similar to in-toeing but reversed in-terms of torsion.

Skeletal Causes:

• Femoral Retrotorsion: the femur (thigh bone) is rotated out leading the rest of the lower extremity to turn out.

  • Potentially associated with Slipped Capital Femoral Epiphysis (SCFE) which is ruled out via an x-ray and is a serious medical condition. SCFE is a condition where the head of the femur slips off the neck of the femur. Seen primarily in males during early adolescents

  • Legg-Calve-Perthes (LCP) may also cause toe-out. This is a condition where the head of the femur stops getting blood supply and the bone begins to die or become necrotic. This is also ruled out via x-ray and is a serious medical condition. Primarily seen in boys ages 6-10.

• Tibial External/Lateral Torsion: the tibia (lower leg bone) rotates outward causing the foot to turn out as well.

• Flat feet: the collapse of the arch sends the toes out to the side in compensation for the arch position. The “too many toes sign” is a good indicator that potentially flat feet are leading to your child’s out-toeing presentation.

Demonstrates flat feet causing out-toeing posture.

Non-Skeletal Causes:

• Neurologic conditions: like cerebral palsy can lead to out-toeing just like in-toeing. The spasticity changes their gait pattern and causes different muscle tightness.

• Breech Birth/External rotation contracture: Sometimes when an infant is in the womb with their legs flexed up and turned out they may start life with tightness that keeps their legs turned out. This typically diminishes as soon as they start weight bearing and walking independently.

Does my child need treated?

In all likelihood the answer is NO! Most typically developing children will naturally develop a mature gait pattern and their rotation of their leg will normalize as they age. However, if the gait pattern is causing pain, excessive tripping/falling, or difficulty with keeping up with peers or learning new motor/coordination skills then likely your child will benefit from physical therapy intervention. If your child has a co-morbidity that could lead to spasticity or low tone that may affect their gait pattern you child will likely greatly benefit from therapy.

Spontaneous in-toeing or out-toeing:

• Did you child just start in or out-toeing spontaneously without a gradual increase in presentation? Are they limping and complaining of pain either in their hip or knee?

• If this is the case, then I highly recommend visiting your pediatrician ASAP. LCP and SCFE (mentioned above) are serious conditions of the pediatric hip and need medical intervention.

Physical therapy to the rescue!

Physical therapy will work to address the gait pattern your child presents with through a variety of interventions. PT goals are typically not to completely eliminate the gait pattern as it may be from a boney alignment issue that will self correct over time. PT goals are traditionally to decrease any pain associated with the pattern, promote age appropriate balance, strength, and functional mobility skills, and decrease tripping/falling to prevent other injury from occurring secondary to the gait pattern.

Strengthening

• In both gait presentations children tend to present with weakness in their hips, core, and other leg muscles. PT focuses on strengthening those muscles found to be weak during initial evaluation to promote better control of a neutral leg alignment.

Stretching

• Obviously tightness is involved with either gait presentation. During your initial assessment your physical therapist will determine if your child has any tight muscles and give you exercises to help stretch them

• Examples:

  • Butterfly stretch for in-toeing to help lengthen adductors and internal rotators of the hip

  • Piriformis stretch for out-toeing to help length the external rotators of the hip

Orthotics

A taping technique to promote neutral alignment from in-toeing

• Research on orthotic interventions such as foot plates etc is not favorable for use to help with in-toeing or out-toeing

• However, if the orthotics are just to treat the flat foot presentation that may be a contributing factor to your child’s gait pattern then they are recommended and at the minimum will not negatively effect the gait pattern.

• However it is important to note that most young children present with a typical and normal pes planus until ~ the age of 4. Children under 4 bear weight through their entire foot and the medial arch does not start to develop until ~ 4-5 years of age. Your physical therapist will determine if your child’s feet are more pes planus than is typical and if they would benefit from orthotics.

Re-training gait and functional movements

• The meat and bones of physical therapy!

• Use of visual cues and verbal cues to help during specific exercises

• Use of manual therapy techniques like wrapping or taping to promote improved alignment during exercises

• Games that encourage playing with correct alignment working on balance and neutral alignment during gross motor and coordination skills.

• For in-toeing especially recommendation to have your child sit criss/cross applesauce instead of W-sitting which may be their preferred method.

If your child is a pigeon or duck walker, likely they don’t need medical intervention just observation and your reassurance that your child will continue to develop normally. If you are concerned consult your pediatrician or a pediatric physical therapist for a recommendation on whether or not they need skilled intervention.

Autism and the Role of Physical Therapy

Here at Milestone Pediatric Therapy we are celebrating National Autism Awareness Month. Dr. McIntyre wanted to highlight the new and evolving role of pediatric physical therapy in helping children with ASD improve not only their gross motor function but their social function as well! With more and more research out every day on the important link between motor development and social development, pediatric physical therapists like Dr. McIntyre take on a more important role in the therapeutic interventions for these wonderful and unique children.

What is Autism Spectrum Disorder?

Autism Spectrum Disorder (ASD) lately has been in the news every where. You may think you have a good grasp on “what” ASD is but many people don’t understand/know all the pieces that actually go into an ASD diagnosis. Autism Speaks defines Autism as the following:

“…broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication”

The CDC estimates that likely 1/59 children in the US are affected by Autism or are on the Spectrum. Most children are diagnosed with Autism between the ages of 2-3 years old but can be diagnosed as early as 18 months if there are other developmental delays present. The most basic symptoms of ASD are

• social, communication challenges AND

• restrictive, repetitive behaviors

These behaviors begin in early childhood, persist, and interfere with daily living.

ASD often has associated medical issues with their GI tract, sleeping disorders, and other mental health conditions such as anxiety. ASD also deals with a variety of sensory sensitivities and coordination/movement disorders which may or may not be related to their sensory sensitivities.

All individuals with ASD present completely uniquely and there is no set rules to how each case will present. Early intervention through a variety of therapies has however been shown to help these children reach an more independent function in adulthood. Some children with ASD will always need some level of support with their daily activities but other children with ASD grow up to be fully functioning independent adults.

For more detailed information and checklists of behaviors visit Autism Speaks.

But if Autism is more of a social issue…why do they need physical therapy??

Recent research has begun to show differences in motor planning and sequencing in children with a diagnosis of ASD. Other research has been showing a gross motor and coordination delay in children with Autism as well. The newest research has shown as early as 9 weeks old children with eventual diagnosis of Autism demonstrated decreased midline head control.

Sensory sensitivities may also lead to other changes in motor development and movement strategies. Children with ASD are more likely to toe walk, avoid activities that may invoke gravitational insecurities, or only participate in singular activities that stimulate their sensory system in a way they like. This leaves them with uniform motor patterns and lack variety of exploration of movement to develop their vestibular system, balance system, strength, and other gross motor skills.

So why does this matter? So what if they have some motor delays… don’t they need more work on their social and behavioral skills? Well…An important study recently showed a large correlation between social skills and gross motor skills in children with ASD. Those with higher gross motor skills also had higher social skills. Those with poorer gross motor skills (specifically object manipulation skills) and poor core strength/stability demonstrated the most delays in social and behavioral skills. This has a large implication for physical therapy to address the impact of motor development, core strength, and ball skills in children with autism.

Benefits/Role of PT

While studies looking at the specific benefits on social skills and function from physical therapy intervention are still coming down the pipe line… there is plenty of anecdotal evidence and research to support physical therapists should begin to take on a greater role in the treatment approach for children with ASD. Working hand and hand with a child’s occupational, speech, and behavioral therapist, a physical therapist could incorporate other therapeutic goals into a session while working on strength to climb a playground and sharing a swing with another child.

Physical therapists are movement experts. As a pediatric PT, we aim to work on optimizing a child’s movement to promote play. And play is a highly social activity for most children. In order to engage in ball play you need to be able to make eye contact with your peer then catch the ball while having enough stability and balance to manipulate that same ball and throw it accurately back. There are huge motor planning, core strength, and balance implications at play here and PT’s work on all those things with children with ASD.

Potential Benefits from Pediatric PT for a child with ASD:

• Increased arm, leg, and core strength

• Improved balance and dynamic control of self through space

• Improved stability

• Improved ball skills and object manipulation skills

• Improved coordination

• Improved gait pattern (if the child is a toe walker or struggling with obtaining the ability to walk or run)

• Improved gross motor skills

• Support with gross motor exploration and exposure to new motor tasks

• Improved participation in physical activity (keeping them healthy and preventing health decline as the child ages into adulthood)

  • A new study in 2018 looked at a 48wk exercise program that improved quality of life, metabolic measurements, and autistic traits in the experimental group of children ages 6-12 years with ASD. This study is supporting the role of the physical therapist in promoting physical activity (PA) participation and getting a child with autism involved in community level PA.

Treatment at Milestone

Here at Milestone, Dr. McIntyre recognizes how unique and individual each child with Autism presents. To quote Dr. Stephen Shore ~

“If you’ve met one person with autism, you’ve met one person with autism.”

Dr. McIntyre works to design a program just as unique as the individual when working with the family and child with Autism. She takes into consideration the family’s goals, the child’s specific behavioral traits, sensory sensitivities, and personal likes/dislikes when designing her physical therapy intervention program. She also works to incorporate a child’s other therapists into the plan of care. She reaches out to occupational, speech, and ABA therapists for their goals and therapeutic advice for working with each specific child. As with any client, a child with ASD benefits so much more from a continuum of medical care and coordination between providers. Early physical therapy intervention could dramatically improve your child’s ability to socially play and interact without the barrier of physical limitations.

As more and more research continues to show tie between gross motor/coordination development and social function, physical therapy will continue to take on a more and more important role in facilitating the activities of daily living, school access, and participation in peer to peer play in children with ASD. Hopefully with more referrals and access to pediatric physical therapy research on children with ASD will also begin to demonstrate where PT can be most effective in helping these children reach their goals and promote independent function in our world.

Resources

AutismSpeaks.org

Downey et al. Motor Activity in Children With Autism: A Review of Current Literature. Journal of Pediatric Physical Therapy. 2012

Gima et al. Early motor signs of autism spectrum disorder in spontaneous position and movement of the head. Experimental Brain Research. 2018.

Haylie et al. Children with Autism Spectrum Disorder, Developmental Coordination Disorder, and typical development differ in characteristics of dynamic postural control: A preliminary study. Gait and Posture. 2018.

Holloway et al. Relationships Between Gross Motor Skills and Social Function in Young Boys With Autism Spectrum Disorder. Journal of Pediatric Physical Therapy. 2018.

Lane et al. Motor Characteristics of Young Children Referred for Possible Autism Spectrum Disorder. Journal of Pediatric Physical Therapy. 2012

Rosales et al. sEMG Analysis During Landing in Children With Autism Spectrum Disorder: A Pilot Study. Journal of Pediatric Physical Therapy. 2018

Toscano et al. Exercise Effects for Children With Autism Spectrum Disorder: Metabolic Health, Autistic Traits, and Quality of Life. Percept Mot Skills. 2018 Feb;125(1):126-146. doi: 10.1177/0031512517743823. Epub 2017 Dec 9.

Aquatic Therapy Comes to Milestone Pediatric Therapy!

Milestone Pediatric Therapy is so EXCITED to announce that Dr. McIntyre will now be offering and performing aquatic physical therapy in addition to all her other clinical services! This blog introduces you to what aquatic therapy is, what the benefits are, and what types of kids make great gains in the water!

What is aquatic therapy?

Aquatic Therapy is defined as a “practice of physical therapy with therapeutic intent toward the rehabilitation or attainment of specific physical and functional goals of individuals using the medium of water” (G-R et al.)

Aquatic therapy is basically physical therapy (sometimes occupational therapy) performed in water. Aquatic therapy uses the following principles to it’s advantage to effect each client toward his/her goals.

• Buoyancy

• Relative Density

• Viscosity

• Resistance

• Hydrostatic pressure

• Turbulence

• Flow

Without getting into the nitty-gritty of the physics of it all, the physical therapist uses these principles to work on a multitude of PT goals such a strengthening, stretching, weight bearing, gait training, vestibular training, and some sensory/behavioral interventions. Water offers multiple sensory stimuli through water temperature, weight relief, and vestibular input. (Mortimer et al) Traditionally performed in a therapeutic pool with a typical temperature of 90degrees F- aquatic therapy can be performed in any community pool setting depending on therapeutic goals.

Here at Milestone we are perform aquatic therapy in the indoor Jim Barnett Pool in Winchester, VA. Jim Barnett Pool offers a 86-88d temperature, shallow stairs to help with entering the pool as well as therapeutic exercise, and a large shallow section for Dr. McIntyre to work with her clients in a one-on-one setting.

So what are the benefits of aquatic therapy compared to land therapy?

There has slowly been an increase in available research and articles on the benefits of aquatic therapy in different pediatric populations. There is still not a lot of clinical trial research out there but there are a lot of case studies and anecdotal evidence of the positive impact of water when combined with land therapy.

Using the properties of water, aquatic therapy can assist with anti-gravity movements in children who struggle to move against gravity and conversely the resistance the water provides can help strengthen those same muscles depending on the therapeutic intervention being performed. Water can help support positive postural positioning allowing a child to work on standing, walking, or other fundamental motor skills in a safe supported environment. Water will also have an un-weighting effect that will improve a child’s ability to weight bear independently and perform these same critical skills.

With a warmed pool and deep pressure, spastic muscles have the potential to be promoted to relax and allow for greater stretching and better alignment. Water can also promote improved circulation as well as challenge the cardiovascular system promoting increased activity tolerance and endurance.

Aquatic therapy has been shown to have a positive influence on activity participation, motor skills, and social interaction/behavior in many different pediatric populations including autism and cerebral palsy. The pool provides a great opportunity for social interaction which can facilitate language development, improve self esteem, self-awareness, and a sense of accomplishment. (Mortimer et al)

Recent research looking at a combination of aquatic therapy and land therapy in the early intervention population (0-3years of age) showed greater gains in parent satisfaction and gross motor attainment with pool therapy. Another study demonstrated increased walking speed after implementation of aquatic therapy. Something all the studies who looked at a long term follow up (6-20 weeks post-intervention) showed was the excellent retainment of improvements and progress seen at the conclusion of the aquatic therapy treatment sessions.

So what kind of child benefits from this type of therapy?

Several different patient populations can benefit from aquatic therapy and your therapist will help determine whether or not aquatic therapy is right for you and your child. The following are some examples of patient populations studied in the research:

Aquatic therapy is just as fun as land therapy…and depending on the child you talk to maybe even more FUN!

Picture From Gillette Children’s Hospital.

• Neuro-developmental (peripheral and central): this includes children with cerebral palsy, stroke, and spina bifida

• Genetic Conditions: including Down Syndrome, Triple X, and Muscular Dystrophy

• Autism Spectrum: Research has shown that there is an increase in positive social interaction and decrease in hostile/antisocial interaction in this patient population with aquatic therapy.

• Psychomotor delay: slowing of physical movement in an individual, typically associated with depression

• Musculoskeletal disorder: orthopedic injuries or surgery that might need a period of decreased weight bearing. Aquatic therapy excels at allowing for rehab to occur in a protected way while not breaking protocol.

Ideal Treatment:

There is a some studies on what is recommended for the best gains utilizing aquatic therapy to reach therapeutic goals. Most studies looked at 60 min sessions in the pool once or twice a week. However, a study that showed the best gains in gross motor skills, combined one land therapy and one aquatic therapy session throughout the week. After synthesizing the research Dr. McIntyre recommends the following treatment protocol depending on client goals and tolerance:

Once weekly aquatic therapy session x 30-45 minutes combined with once weekly land sessions x 60 minutes

This will help produce the greatest gains utilizing aquatic therapy. The client will be able to work in the pool then carry over their gains into a land session to work on more critical independence in full weight bearing.

Interested in Aquatic Therapy?!

Aquatic therapy is a great way to train and develop a multitude of body systems within a single therapy session not to mention it is great FUN and super motivating for the child participating in the session. Dr. McIntyre is excited to be able to offer this awesome services to the Winchester area.

If you are interested in aquatic therapy for your child please reach out to Milestone Pediatric Therapy to schedule a complimentary consultation or your initial evaluation today.

P: 540-724-1757

Or contact us through our online portal!

Resources:

Academy of Pediatric Physical Therapy: Aquatic Therapy Fact Sheet. 2017.

Declerck et al. Benefits and Enjoyment of a Swimming Intervention for Youth With Cerebral Palsy: An RCT Study. Journal of Pediatric Physical Therapy. 2016.

 Fragala-Pinkham et al. An Aquatic Physical Therapy Program at a Pediatric Rehabilitation Hospital: A Case Series. Journal of Pediatric Physical Therapy. 2009.

Güeita-Rodríguez et al. Identification of intervention categories for aquatic physical therapy in pediatrics using the International Classification of Functioning, Disability and Health-Children and Youth: a global expert survey. Journal of Brazilian Physical Therapy. 2016.

McManus et al. The Effect of Aquatic Therapy on Functional Mobility of Infants and Toddlers in Early Intervention. Journal of Pediatric Physical Therapy. 2007.

McManus et al. THE EFFECT OF AQUATIC THERAPY ON PARENT SATISFACTION WITH EARLY INTERVENTION SERVICES AND CHILDREN’S GROSS MOTOR SKILLS.Abstracts of Platform and Poster Presentations for the 2005 Combined Sections Meeting. 2005.

Mortimer et al. The effectiveness of hydrotherapy in the treatment of social and behavioral aspects of children with autism spectrum disorders: a systematic review. Journal of Multidisciplinary Healthcare. Feb 2014.

Pediatric Flat Foot

This blog post starts a series of post on the different types of conditions that Dr. McIntyre treats at Milestone Pediatric Therapy. We will be starting out with a common condition in the pediatric world that while easy to treat with physical therapy and orthotics can potentially lead to unsuspecting consequences if left untreated.

Pediatric Flat Foot

Or bilateral pes planus (if you want the medical lingo) is a common pediatric condition where a child’s feet demonstrate minimal medial longitudinal arch development when they are in a weight bearing posture (i.e. standing or walking). Pediatric flat feet is a NORMAL part of the development of the structure of a child’s foot. ~97% of 2 year olds have a classification of flat feet and this presentation should resolve by the time a child is 10 years old (incidence as low as 4%). Recent research suggests that 3-6 years old is a critical time for medial longitudinal arch development given that only 26% of children have flat feet by the time they are 6 years old.

There are two types of pediatric flat foot. Flexible flat foot refers to a condition where the medial longitudinal arch is present in non-weight bearing postures. Rigid flat foot refers to a condition where the medial longitudinal arch is not present in weight bearing OR non-weight bearing postures. Typically rigid flat foot is associated with bony anomalies of the foot/ankle structure.

These feet show an example of the “too many toes sign” as well as a change in the angle where the lower leg meets the foot.

Pediatric Flat Foot is typically not considered pathological/symptomatic until a child complains of pain or excessive fatigue in their feet or legs, demonstrates poor balance or development of gross motor/coordination skills, or if the condition is associated with a greater developmental diagnosis (such as Down Syndrome).

Clinical Tests: there are a few easy tests to see if the flat foot is rigid or flexible and the child has the potential to spontaneously develop an arch over time with typical development or with mild orthotic treatment. Your physical therapist (or podiatrist/pediatrician/orthopedic MD) can perform these assessments and make a determination if your child needs orthotics and physical therapy or just to be monitored.

Potential associations/consequences:

There are some co-morbidities and other associated conditions that have been studied by the research and have shown to have some link to pediatric flat foot. Although the researchers are not sure which “comes first” with these scenarios, pediatric flat feet is typically seen in conjunction with the following conditions. (luckily physical therapy can help address a lot of these issues!!)

Flat feet place an internal rotation moment on the leg potentially causing toe-in. Flat feet can also cause the “too many toes” sign which might look more like toe-out when watching them stand and walk

Muscle Weakness: Core, hip, and lower extremity weakness is a typical finding during a physical therapy evaluation. Flat feet could contribute to this weakness by placing muscles as a disadvantage and vice versa as weakness can lead to decreased arch formation.

Mal-alignment/rotation of leg bones: Whether the toes be turned in or turned out- both are seen with some kids with pes planus. The increased loading of the medial foot can lead kids to rotate their legs to help with re-aligning themselves for better movement.

Hyper-mobility: Kiddos with excessive mobility (potentially from a genetic condition etc.) are at higher risk for pes planus presentation because the ligaments/joints in their feet are far more mobile. And the longer a child is developing in pes planus (beyond what is considered normal age- remember flat feet is normal until at least 6 years of age potentially 10years old depending on the literature you read) the more mobile the ligaments and joints in their feet become. In the case of a child with a genetic/neurological condition, orthotics may potentially be recommended even earlier depending on the severity of their foot position.

Foot and leg pain is a symptom you will want to bring to the attention of your pediatrician.

Obesity: The link here is an interesting one and not super well studied yet. The incidence of pes planus is much higher in children with obesity. Research does not show causation of one from the other but there is indeed a correlation between the two. Potentially because their feet are flat they have a harder time moving (remember weak muscles) so therefore play less and gain more weight… or because they have more weight it collapses the medial arch? No one knows for sure and maybe both reasons play into each other over time.

Pain/Fatigue: Given the changes in alignment and muscle firing patterns this can lead to pain and increased fatigue from changing pattern of stress on the body. Many of these kids complain of pain or fatigue after playing all day or going for long walks. Listen when your kids complain of consistent pain as any pain in a child is considered at least a yellow flag by medical providers and should be evaluated.

Treatment

There is not a lot of research on treatment of pediatric flat foot. But the American College of Foot and Ankle Surgeons has a clinical practice guideline on the treatment of this condition. Summarized:

Asymptomatic: observation is the best treatment

Symptomatic: physical therapy, over-the-counter orthotics, anti-inflammatories, rest; surgery is rarely indicated (mostly for rigid flat foot or boney abnormalities- to be determined by your child’s podiatrist or orthopedist)

A physical therapy evaluation of pediatric flat foot is always a good idea if your child is complaining of foot/leg pain, excessive fatigue, and you are noticing increased tripping/falling or trouble with balance and gross motor skills. If your physical therapist determines your child needs PT you can expect some of the following activities to help your child reach their goals:

Cascade DAFO makes great over-the-counter orthotics like the “Bug.” A clinician must measure your child and make the appropriate clinical determination on which type of orthotic would help best (be supportive without being overly supportive!) as well as any add-ons and modifications your child’s feet may need!

An orthotic recommendation: depending on your child’s severity of pes planus these may be over-the-counter or custom

Stretching: many times children with pes planus have tightness in at least their heel cords, if not other muscles like their hamstrings.

Strengthening: It is important to work on hip, core, and leg strength to help promote their gross motor skills and other delays. As well as working on inner feet strength with marble pick ups or other small object. - working on internal feet muscles (called intrinsic foot muscles) is VERY important in this population because those muscles can help support their medial arch while in weight bearing postures.

Balance training: many times these children have difficulty with balancing on one leg because of the flatness in their feet or weakness in their core (or both!). Balance exercises can have a whole body benefit for children with pes planus.

Manual interventions (if necessary): may include soft tissue interventions for painful muscles and taping for arch support

Resources/Citations

Diagnosis and Treatment of Pediatric Flatfoot: Clinical Practice Guideline. The Journal of Foot and Ankle Surgery.

Pes Planus and Pediatric Obesity: A Systematic Review of the Literature. Stolzman et al. Clin Obes. 2015 April ; 5(2): 52–59

Pathology and management of flexible flat foot in children. Ueki et al. J Orthop Sci. 2019 Jan;24(1):9-13. doi: 10.1016/j.jos.2018.09.018. Epub 2018 Oct 23

Carr JB, Yang S, Lather LA. Pediatric Pes Planus: A State-of-the-Art Review. Pediatrics. 2016;137(3):e20151230

The CORE of Development!

As a pediatric PT I spend the majority of my time with kids working on developing the appropriate core strength and dynamic control they need as a foundation for many other skills. This blog goes over core muscles, why core strength is even important, how it is interwoven into so many of your child’s daily activities, play, and development, and gives some ideas for working on core strength at home!

The Plague of the 6-Pack

Diagram of Core Muscles.

Image from Harvard Health Publishing.

When I talk about developing a child’s core I am NOT talking about getting them a 6-pack. A common misconception is that the “core” is only the muscles on the front of the trunk. But a child’s core strength actually comes from an interplay of anterior (front) trunk muscles, posterior (back) trunk muscles, and hip muscles. Much like a puzzle, a child’s core isn’t complete unless you work on all the pieces. Below is a non-exhaustive list of important core muscles.

Anterior Superficial Muscles:

• Rectus Abdominus

• External Obliques

• Internal Obliques

• Transverse Abdominus

Anterior Deep Muscles:

• Quadratus Lumborum

• Psoas and Illiacus

Posterior Muscles:

• Erector Spinae

• Multifuidus (not depicted)

• Latissamus Dorsi (not depicted)

Hip Muscles:

• Gluteus Maximus

• Gluteus Medius

• Gluteus Medius

• Piriformis (and all his very small friends; not depicted)

In kiddo’s with low tone these muscles tend to lack strength to function to help with stability during movements. In kiddo’s with high tone, these muscles tend to lack synergy and the ability to dynamically integrate with one another to allow for fluid and controlled movements.

Kid’s Cores are their FOUNDATION

Ok cool, cool…so lots of muscles but who cares? Without getting extremely technical, kid’s need their core for everything from developing their gross motor skills, to learning to eat, developing cognitive skills, and even language.

Every house needs a stable foundation in order to stand!

Gross Motor Development:

Think of core strength as the foundation of your house. Without that the house would surely fall over- there is nothing stable to build walls or a roof on. Without core strength, their is nothing stable to build new skills on. Head control only comes with the development of cervical core strength—>this leads to stability through the trunk for sitting—>dynamic control then leads to crawling and then walking—>eventually core strength determines a kiddo’s ability to balance on one foot, jump, and run with their peers on the playground.

Eating and Language Development:

So obviously core strength is needed for gross motor skills! But what about other skills? Imagine being a bobble head doll… imagine trying to learn how to speak or to eat if you couldn’t control your head at all? With a lack of core strength this is what kiddos face! Heads are darn heavy! If core muscles aren’t developed then they will have difficulty stabilizing their head to swallow…they won’t have the breath support to be able to vocalize sounds…or a stable center for their tongue to develop its fine motor control needed for speech.

Fine Motor Development:

If you imagine the trunk as a “yoke”: something that stabilizes extremities in order to affect the external world. Alright now lets place your yoke on something very unstable- a weeble. Do you think your yoke is going to effectively interact with the external world? There is no stability- you have no idea which way that weeble is going to wobble and good luck grabbing that small block to play with or a pencil to write with. Basically the same idea applies to kiddos without trunk control. Their shoulders/arms are “yoked” into their trunk. If their trunk is unstable they have no way to refine and develop graded movement and reaching patterns for objects in their external environment. And you can but say goodbye to fine enough control to manipulate those objects in a functional way. Examples are writing legibly or feeding oneself.

Cognitive Development:

Alright you probably think now that I am stretching this core strength thing… I promise I am not! This time imagine you are driving a car for the very first time. You can ONLY concentrate on the road and driving—> no way in hell you are going to reach for the stereo button or attempt dual task in anyway not until you’ve mastered the skill anyways! Alright now let apply this to a kid- they can’t control their trunk and head very well—> they are in sitting and sitting is HARD. All their mental faculties are concentrating 100% on sitting and staying upright. This leaves no room for cognitive development and environmental exploration needed to continue that trend in development. (see wasn’t that much of a stretch!)

Does my child have core weakness?

There are some hallmark signs for core weakness- most of which make sense.

• Global delays in development- including gross motor and fine motor skills.

• Lack of variety of movement patterns (think- sitting the exact same way every time they sit)

• Difficulty sustaining postures for long periods

• Would prefer laying down to play

• Sitting in “W-Sit” or in a rounded posture

• Open mouth/excessive drooling presentation

• Flat feet/in-toeing

A physical therapist can easily evaluate your child for core weakness if you suspect there is an issue resulting in decreased participation and functional abilities.

5 easy ways to work on your child’s core strength at home!

PT’s give exercise prescription and just like medication, if not “taken” in the proper way it will have no effectiveness on increasing core strength and activation. I recommend working with your kid at least 3x/week for at least 30 minutes/day to make any true changes in strength. It doesn’t have to be 30 consecutive minutes but accrued throughout the day will also work.

1. Balance games

This includes balancing on one leg or in a half kneeling posture. Trying playing catch in this position to make it fun! Another fun way to challenge balance is to pick up marbles with toes and place them in a bucket. <- This might be a fun way to challenge your kid to help with cleaning up their toys!

2. Homework/reading positions

Think sitting on a ball while doing homework or playing video games! This will challenge their core without taking any time away from your already busy schedule! Other positions might be in half kneeling or standing on an unstable surface.

3. Yoga

I LOVE YOGA FOR KIDS. Find a youtube video (Cosmic Kids) or do Yoga Pretzels together to work on core. Challenge your kiddo to hold for longer or try a new, harder pose.

4. Animal walks

As listed in a previous blog animal walks work on SO MANY THINGS. One of which is core strength. Be creative! Make animal walk dice. Have your kid roll and see which animal they have to be while completing a puzzle or other small object game.

5. Obstacle courses

These are the best when it is nice outside (depending on your opinion of leaping on furniture!) Your imagination is your only barrier when it comes to obstacle courses. Add balance beams, ladders, tunnels, jumping over things/on things, moving from “island to island”…stick a section of animal walks in the middle of it! You can literally create anything and give your kids hours of fun doing it! Pinterest is full of extremely awesome and easily set up versions to try in your own home!

Tummy Time to Play

Being a pediatric PT, I get asked all the time “how can I make tummy time for my child more enjoyable? All they ever do is cry in the position!” The answer is scarily simple but for most parents who have either never had a child or had an easy going baby who liked tummy time to start off with they might not be able to come up with answer on their own. The answer, of course, is PLAY. Tummy time is no fun if you are down there by yourself struggling to hold your head up and no one is playing with you or helping you engage in the environment! This blog post dives into why kids aren’t getting enough tummy time anymore and the implications of that; how to improve and make sure your baby gets enough quality tummy time; how much tummy time is appropriate, what are some of the awesome benefits of enough tummy time and so much more!

Tummy time is so fun!

The Safe to Sleep (Back to Sleep) and Tummy Time for Play Relationship

As many of you know, the Safe to Sleep (formerly Back to Sleep) Campaign has reduced the incidence of SIDS by 50% since its institution in 1994 by the American Academy of Pediatrics. However, many studies have shown that there is also an associated decline in gross motor function, social, and overall development at 6 months of age in infants who supine (back) sleep. Further follow up studies to these original studies showed that the decline in motor skills was more correlated to a lack of prone (tummy) time spent while awake and alert. When the Safe to Sleep campaign started, the pendulum ultimately swung very far toward the “scared to place my child on their tummy for fear of SIDS direction.” This prompted a change in language and new recommendations by the American Academy of Pediatrics encouraging parents to make sure their babies got enough prone time while awake to mitigate the delays in gross motor development from supine sleeping. The AAP encourages increasing tummy time to play while alert and supervised by an adult and also educating that prone time spent during play will not have negative consequences on your baby while they sleep (actually might positively impact their sleep but more on that later in the blog!)

Hmm…wonder how I can get more tummy time??

My kid hates tummy time…do I really have to make them do it?

So your kiddo hates tummy time eh? Scream bloody murder the moment you put them down? Feel like a horrible parent for making them cry so hard? Well don’t! Babies hate tummy time because it is hard and crying is their only way of protest. And tummy time is hard because they don’t practice it enough to get strong enough for it to be easy! Heads are VERY heavy compared to their small baby muscles and gravity is mean and unrelenting. So you as the parent have to find ways to make tummy time just easy enough that they don’t hate it for long enough to get them stronger so that they can do tummy time as normally as possible… in a few short words, “Suck it up, buttercup, put your kid in tummy time!”

Of course, I hear your retort… “But why do I really have to ? Is it that bad for them?” The answer is YES, yes you do! and Here are some reasons why NOT having tummy time is BAD

• Cranial Deformities: Medically known as plagiocephaly or brachiocephaly. There has been a dramatic spike in these types of conditions since the implementation of the Safe to Sleep Campaign. Increasing the amount of time spent on their belly helps to reduce the risk of deformation from supine lying over time in cribs or carriers.

• Gross Motor Delay: There are 4 developmental positions that are assessed for an infant’s development: Supine (back), prone (tummy), sitting, and standing. If tummy time is developmentally missed (a crucial developmental position), a child will end up developmentally missing or delayed on many motor skills including locomotion. Some of these kiddos decide to never crawl…

• Why crawling matters: There has been research and some known correlations between hand writing/reading proficiency, fine motor skills, hand/eye coordination, bi-manual coordination and whether or not a child crawled prior to walking. Crawling which is a progression of prone into quadruped (hands and knees) position and works on integration between upper limbs, vision/perception, and dissociation between the LE’s in preparation for walking. Therefore if tummy time is missed, likely a child will be delayed in crawling, which may potentially lead to decreased proficiency in many other areas of development as they age.

Alright so there are some of the negatives to not doing tummy time… But what about the positives? Why is tummy time good?? The infographic below has some great summary information on all the benefits! But below that you’ll find some of my elaborations on a few of the key points.

This infographic is a perfect summation of all the benefits of Tummy Time for Play.

By Rmpathak73 - {{Tummy Time Guide Infographics}}, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=71229367

Explained…

• Strengthening: As your baby works against gravity they are working all of the head, neck, trunk/core, and hip muscles to keep their head up and looking at the world. Gravity is your babies biggest work out motivator and biggest rival when it comes to learning to control their own bodies. The more time they spend on their tummy working against gravity the faster they’ll become stronger and more capable of controlling themselves in space.

• Fine motor skill development: As your baby works on pressing up, shifting side to side, and reaching, they are laying down the foundations of skills to work on fine motor and grasping skills.

• Sensory Processing: Because of the intense amount of body/skin contact with whatever surface they are laying on a baby gets a large amount of sensory input about their position in space as well as tactile information from the surface they are on. This information then goes back to the brain to help them learn how to process tactile input more effectively as well as help them develop an increasing more clear body image of themselves and proprioceptive sense (position of body in space).

• Hand Eye coordination: Because their hands are directly in front of their developing eyes in this position a baby learns more about where and how to move their hands to benefit them while in this position- whether it be reaching for a toy or figuring out how to roll themselves out of the position!

• ***New Research also suggests that babies SLEEP BETTER when they get an appropriate amount of tummy time a day! There are also some other interesting ties to weight and childhood obesity that you can read about in this article.

Tummy Time can do all that??

Photo by Silvia Trigo from Pexels

How much tummy time is enough tummy time??

Depending on the age of your baby, the recommendations for tummy time change. But as a rule of thumb, the older they are the more time they should be spending on their bellies and the more they should want to be there! Our goal is to get enough tummy time to mitigate the negative consequences of back sleeping on their development- and turns out it isn’t THAT much time needed to really help them along!

• 0-3 months:

  • Yep that’s right! You can start tummy time the moment that baby gets here! I know a concern that parents may have is damage to the umbilical cord/area, but that is just a wives’ tale! It is perfectly safe and highly encouraged to start your baby even in their first couple days of life with some form of tummy time. Whether that be skin to skin on your chest in a reclined position or as they get a little older over your lap or boppy pillow.

  • Up to three months old, as a parent you should be aiming for 30 min to 1 hour of accrued, QUALITY tummy time a day (building up from day one so that by three months they can roughly get 1 hour). That means 5 minutes here and 3 there… and another 10 when they were happy and awake and lifting their head up even briefly (thats the quality part)! If your baby just happens to lay their head down and rest in this position, it does not count as active quality tummy time and should not be counted in the overall amount.

• 4-6 months

  • At this stage, your baby is getting pretty good at tummy time and starting to roll, reach for objects, and hold themselves easily there. They can interact with their world without a lot of effort but still may need some modifications to make tummy time interesting/enjoyable. That includes lots of cool toys to hold their interest or having a parent down on the floor playing along.

  • 1-2 hours of accrued tummy time a day is your goal by 6 months of age! With either tummy time or sitting positions being the preferred position of play for babies at 6+ months of age. A typically developing baby who is that age and still preferring back play desperately needs other positions encouraged because they are coming to a period in brain development where self-environmental exploration is key.

• 6+ months:

  • Your baby will soon be learning how to get into and out of all of their development positions and we should see them begin to spend more time in a quadruped position as an advancement of the tummy time for play and begin working toward crawling activities.

  • You should be allowing independent play for at least 2+ hours a day so your baby can practice movements and self-environmental exploration in order to promote development of new skills. Make sure you have plenty of toys to help engage them in exploration of their environment. See my toy blog for ideas on appropriate toys for this age!

I can see your eyeballs growing bigger now! How can I get my baby to do all that tummy time you say…well keep reading! Its easier than you think!

Tummy Time comes in many different shapes and sizes

Luckily tummy time is easily modified to increase your baby’s tolerance of the position while still getting the benefits of being prone!

• Laying on your Chest/over your shoulder

  • Best for 0-3 month olds

  • Lay your baby in a reclined position either over your shoulder or on your chest.

  • Chest: easy way to engage with your infant to make tummy time fun! They can see your face fairly easily and will be encouraged to lift their head.

  • Shoulder: for the kiddo who LOVES to look at the world and will keep their head lifted to see what is going on

• Over your lap or over a large ball (if you have one)

  • Best for 2-4 month olds

  • In a sitting position with both of your legs together, lay your baby over your lap so their arms are off the side and on the chair/surface you are sitting on or propped on your leg.

  • If using a ball, lay your baby on the ball and roll them forward and backward until you find the position where they can successfully lift their head up to see the world in front of them. The ball will help you decrease the amount of gravity pulling on them thereby making the position easier.

  • Make sure there are toys to engage with or another child/adult helping you with these versions to make them fun and enjoyable!

• Supermans

  • Best for 3+ month olds who have good head control in tummy time

  • First way: Holding your baby around their middle or placing them on your lower legs, “fly” them over your head

  • Second way: carrying them in your arms on their belly and flying like an “airplane”

  • Make sure they are lifting their head and feet against gravity!

• Propped on Boppy Pillow

  • Good for 3+ months old

  • Alternatively: over your leg or towel roll

  • If you don’t already own a boppy pillow, I highly recommend purchasing one. It will help significantly with tummy time immediately as well as sitting posture around 5-6 months.

  • Place your baby on their belly with their chest on the boppy pillow and arms over the pillow and placed in front of them. Place toys that your child finds interesting or get down to their level and play with them in this position.

  • Placing your child on their belly with the pillow increases their success of lifting their head by shifting weight from their shoulders back to their hips.

  • Placing them over your leg leg also has the same effect. The higher up your leg you place your child the easier it is for them because your thigh offers more support than your lower leg because of the height difference.

Alright so now you see how easy tummy time be! As well as how it important it is to get your baby in the position and some of the negatives of not performing this activity. Tummy time can be a great bonding activity instead of one of dread as long as you work on it appropriately with your baby! Help them be successful so they can reach all their milestone and develop to the best of their ability!