Gross Motor Games

While we were on the topic of play I thought it would be a good idea to cover some ways you can encourage gross motor and coordination development in your children while playing games that are enjoyable- and sometimes even just a classic!

This post comes from a presentation I did last week at the Discovery Museum for their Pajama Day. “Reindeer Games” was an hour of gross motor games and activities to get the children attending Pajama Day moving and working on gross motor skills together. I have never sweat so much in one hour of time playing with kids (and it is literally my job! probably had something to do with wearing very WARM pj’s while doing countless frog hops and crab walks!) but it was so much fun and I look forward to going back to the Discovery Museum in the spring!

Work on motor timing, strength, coordination, and endurance!

Crawl, skip, hop, jump!

Gross motor games and play are practically synonymous when it comes to the benefit each gives your child and their development. Specifically gross motor games give your child an opportunity to try new skills and challenges and hopefully excel at them! Gross motor and coordination based games help:

• Develop strength

• Develop coordination

• Develop endurance

• Perfect gross motor skills

• Develop confidence

• Improve social engagement

Types of Gross Motor and Coordination Skills

• Strength: overall ability to perform repetitive tasks with their own body weight. i.e. push ups, sit ups, climb stairs, get on/off the ground

• Whole body coordination: ability to move the body as a unit in multiple different ways. i.e animal walks, skipping, galloping, forward rolling, jump rope, hula hoop

• Ball skills: kicking, throwing, catching, dribbling

• Locomotor skills: skills that involve forward (or backwards or sideways!) body movement. i.e. running, hopping, jumping, roller skating

• Balance: ability to maintain body in an upright posture. i.e balance on one leg, walking on a balance beam, and standing on tip-toes

“Prescribing” Movement

Basically my job in a nut shell… But I digress! How much play/gross motor participation should your child do in order to get the most benefit you ask?? The answer is play with focus on repetition until your child is fatigued or your child is beginning to get frustrated with a challenging task

• Increased repetitions of the same task help with skill perfection and coordination development - practice makes perfect!

• Taking a child to fatigue makes sure things like strength and endurance are capitalized on - they’ll normally let you know when they are tired!

• Stopping prior to extreme frustration will help improve your child’s confidence in a task - watch for behaviors that indicate this is an issue

Bear Walks are great fun!

Ideas for Games to Engage your Child and encourage MOVEMENT

Animal Dice: Take some large dice or 6” square boxes, put the picture of an animal on each side. Have your child roll the dice and perform the animal it lands on. If you have a hallway, perform the “walk” down the hall way. Or if its an animal that stands still- maybe sing a nursery rhyme while standing on one foot! Depending on what animals you perform your child is likely working on ALL aspects of gross motor development (as well as cognitive and their imagination as they pretend to be an animal and figure out how it moves!) Here are some animal moves to consider:

• Bear Walk

• Crab Walk

• Gorilla Walk

• Kangaroo Hop

• Frog Hop

• Wheelbarrow

• Flamingo hop/stand

• Lizard/army crawl

• Dino Walk (lunges)

• Horse gallop

• Inch Worm

• Possibilities are endless! You could even include other coordination activities like skipping, walking on toes/heels, rolling, etc.

Hopscotch: This one is SUCH a classic! On a nice day, take some sidewalk chalk and work with your child on drawing a hopscotch “court.” Get a bean bag and toss it onto the court. Teach your child how to hop from one leg to two and back again. Tossing the bean bag also gets some ball skills working too! If the bean bag lands on a square that is just one, have them try to balance on one leg to grab the bag! If you number the boxes you can also work on counting/etc. if your child is age appropriate!

Jump Rope and Hula Hoop: Another classic… but children get SO PROUD when they can do these things without help or for 100 times in a row or whatever their ultimate goal is! These types of games work on coordination of legs and arms together with a visual/external component added into the mix. Not only do they have to utilize their body in a coordinated effort they also have to manage an external toy in the process! Other acceptable toys would be skip-its, bikes, rollerblades.

I love using these in clinic!

Yoga: This is definitely coming into popular opinion these days! One day I will do a full blog on the benefits of yoga for all children, especially differently-abled kids. For now, I love using yoga pretzel cards (pictured). I have the kiddo I am working with help me arrange the cards I have chosen for the session in the order they want to do them in. I challenge them to hold poses for a certain length of time. Alternatively you could also do the dice game with yoga poses. OR a fun and wonderful way to engage your child in yoga for longer periods is to use a yoga video. One of my particular favorites is Cosmic Kids Yoga on Youtube. She does different movies and adventures and uses yoga poses to help tell the story.

Ball Skills: This is a HUGE category of games. Basketball, baseball, corn hole, soccer, etc. Anything with an object you can throw, kick, dribble, or catch counts when developing ball skills and the necessary coordination to produce an accurate movement and correct body mechanics. The older your child becomes the more accurate you are looking for their movements to be. Either throwing further, being able to kick straighter, or catching smaller and smaller balls. Most children love engaging in this type of play but a lot of times they need adult participation (unless they have developmentally appropriate siblings!)

Awesome well hope you enjoyed! And hope you have fun trying some of these out with your kiddos! Not only will you ultimately help them become stronger, better versions of themselves… likely if you PLAY right along with them you’ll see just as much benefit! Not only physically (example:me while I was playing last week! I’d say it was a workout!) but in the bond you develop with your child!

To Play or Not to Play?

This week I had the exciting opportunity of presenting at the Shenandoah Valley Discovery Museum! I did a presentation on appropriate toy choice for play and wanted to share some of the information that I educated on here in my blog too! Being a part of the Winchester community and building ties is so EXCITING for me. I have already gone out and done community out-reach at preschools/daycares and have another presentation at SVDM on Dec 21 at 2PM for their PJ-Day on gross motor/coordination building games!

But without further delay, lets get into what toys are the best at what ages and stages to promote development!

First things first, why play??

To play or not to play? And the answer will resoundingly ALWAYS be PLAY! Because it is literally your child’s ONLY job! That is why! Children grow and develop through play and we should encourage it as much as possible! Their play involves extreme repetition. One study showed that a baby will practice standing for up to 6 hours a day! Same goes for other skills and they get this practice through play and toy driven activities. The following are a few ways they develop through play and interaction with appropriate toys:

• Develop physical coordination/strength

• Develop emotional maturity

• Develop cognitive and problem solving skills

• Develop social skills to Interact with other children

• Develop self-confidence to try new experiences and explore new environments

Types of Play

There are several types of play that children engage in to develop certain skills as they develop!

1. Sensory rich play: develop smell, touch, sight, hearing, and movement senses

2. Manipulative play: develop hand-eye coordination and dexterity

3. Gross motor/locomotor play: develop whole body coordination, strength, and endurance

So what’s the right toy for my kid?

Each age and stage leads to different cognitive, gross motor, dexterity, and coordination skills as well as different developmental interests in the world around them as they develop. Thus, each age and stage will have a different set of appropriate toys. A toy too easy to play with will be boring and not stimulating enough for our child. A toy too challenging may be off putting and frustrating for your child. Either scenario may lead to behavioral issues or difficulty engaging in appropriate play behaviors. Below is suggestions for toys by Age and Stage and an explanation for each choice!

Bright, colorful, and light weight toys are perfect!

Infants: 0-12 months

Toys should be BRIGHT and Colorful! Should appeal to sight, touch, and hearing senses!

Newborn-3 months

Think visual and auditory stimulation! high contrast black and white images, mobiles, your face/voice are the best toys!

3-6 month

Toys they can easily hold and manipulate on their own! light weight toys, bright colors/high contrast, make noise/music (rattle, crunch, etc.), easily held/teethed on/washed

6-12 month

Beginning stages of interest in cause/effect toys; light weight toys, “busy boards”: includes buttons, items to pull/push, make noise; large blocks and something to put them in/take them out (aka large bowl/basket); cloth, plastic, board books with texture!

Nesting/stacking blocks and cups are great for encouraging movement, understanding of object dimensions, and problem solving.

Photo by Markus Spiske temporausch.com from Pexels

Toddlers: 12-24 months

Toys should be Safe and Unbreakable! They need to withstand a toddler’s Curious Nature

Toddlers also get excited by being able to DO something.

• Simple toys that are easy to stack, pour, scoop, and throw!

  • Think balls, nesting/stacking blocks/cups, sand/water toys

• Push/pull toys (avoid long cords)

• Ride-on toys using foot propulsion

• Musical toys

• Simple shape/color puzzles (only a few pieces)

• Clothe, Plastic, and Board books

• Avoid talking toys as they REDUCE language development: I suggest that you spend more time doing the talking for the toy! Example: “This is a yellow circle!” as you hand the toy to your child. Or if you catch them holding a particular toy “You are holding a red block!”

Sand/water toys to play with work on tactile development, gross, and fine motor skills.

Photo by Kaboompics .com from Pexels

Preschooler: 2-5 Year Olds

This age LOVES imitating YOU and their older siblings! Toys should direct this type of mimicking play.

Locomotor/transportation toys  and Outdoor Toys

• bikes, trikes, wagons, sandbox, swing, slide, balls in a variety of sizes

Imitation toys

• kitchen/household toys (this includes old kitchen items such as pots, pans, and utensils!), dress up, tea party, hammer/bench

Creative Play Toys

• building blocks, crayons/play dough/finger paint

Cognitive Development toys

• short action stories with pictures, large piece puzzles

Outdoor toys that encourage gross motor development, strength, and endurance!

Photo by Agung Pandit Wiguna from Pexels

Early Elementary: 5-9 year olds

Toys for this age should help to build new skills and creativity.

Locomotor and Outside Toys

• Bikes/Roller skates (& protective gear!), sports equipment (basketball hoop, bat/ball/glove), jump rope/hula-hoop

Creative Toys

• Sewing sets, hand puppets, paper dolls, age appropriate crafts

Cognitive Development Toys

• Games: Card games, board games

• Puzzles with increasing complexity /# of pieces

• Age appropriate books – simple chapter books

Board games/card games are perfect for the older child!

Photo by Ylanite Koppens from Pexels

Late Elementary, Middle School, and Beyond: 10+ years old

Hobbies and scientific activities are ideal for this age population.

Hobbies

• Collections, sewing/needle point, crafts kits, model trains/planes/boats, books

Scientific

• Microscope, telescope, experiment kits

Games

• Table, card, and board games; computer games (remember screen time limits); complex puzzles

Outside Toys

• Sports equipment, bikes, scooters, rollerblades (& all necessary protective gear!)

Screen time can lead to decreased physical activity levels and potentially weight gain/obesity.

Photo by Jessica Lewis from Pexels

Hot Topic in Play: Screen Time!

No blog on play and toys would be complete without a mention to the hot topic in child distraction/interaction: screen time! We’ve all done it: A screaming toddler…hand over the phone with some Youtube video on it and screaming quiets…at least for a little while…

Now I am not here to teach you how to parent, that is not my expertise, but I am going to list of the American Academy of Pediatrics recommendations for appropriate screen time and why its important developmentally to limit the amount of time your children are stuck in front of a screen.

Some of the negative impacts of screen time at any age:

• Reduces activity levels

  • Increased risk of weight gain and poor fitness

• Impacts developing brain

  • Reduces problem solving development

  • Emotional development

  • Social Interaction skills

• Impacts development of gross and fine motor skills through play

Recommendations at each age bracket:

• 0-24 months old

  • AAP recommends absolutely NO screen time for this age range.

• 2-5 year olds

  • AAP recommends a max of 1 hour of screen time where you watch with them to help them understand the content and apply it to the real world

• 6+ year olds

  • AAP recommends up to 2 hours of screen time a day for children 6+ years old (Play and Educational Combined), which should NOT interfere with physical activity or sleep

Toys are fun and interactive ways to engage children and help them develop! I hope you found this blog informational. I want to thank the American Academy of Pediatrics for having such a plethora of information and guidelines available on their website to help supplement information for this blog!

On the Road Again!

The Benefits of A Mobile Therapist: Achieving Goals at Home, the Community, and Life

One of the main reasons I decided to open Milestone Pediatric Therapy was I wanted to reach my clients where they were struggling most. The clinic environment, while good for task training and safety, does not in many cases simulate the real world challenges and environment a child may encounter during their day to day lives. A combination of clinic and real-world sessions is often the best recipe for success! The following blog goes over the benefits of mobile therapy for your child, from convenience for your family to meeting real world goals on a playground set.

Playgrounds are places children WANT to feel comfortable!

“My child was so engaged in the session! I have never seen them work so hard!”

That is a quote from a parent after a session at a playground. Both myself and the child were sweaty after having run around the playground using every piece of equipment and overcoming some fear’s the child had about climbing and equipment that required a lot of strength to play on. Working with children at playgrounds, play gyms, and other fun physical activities meets them where they WANT to be. Its a kid’s environment! Many of my kiddo’s aren’t comfortable in them however because they have strength deficits, balance impairments, or social anxiety about playing on equipment they struggle with. Because these children become so engaged in the session, having FUN, they end up working so much harder than they would have in a clinic session. As the therapist, close by, I offer a small comfort blanket while they are trying new things, giving them a confidence boost or lending hand when they have chosen something that might have been slightly too hard for them (again leading to a confidence boost that they COULD do it instead of failing again). I also spend much of the session instructing parents on how to assist their child through the same obstacles so carry over can be better achieved.

Photo by Porapak Apichodilok from Pexels

Real world challenges overcome

Who cares if a child can navigate the stairs at clinic or jump off the stool during an obstacle course? No one does if the carryover isn’t seen while the child is trying to go up the stairs to their bedroom or play with peers at the neighborhood playground. Does your child struggle with a specific task while they are attending gymnastics? Or are unable to get into their church independently for a bible study class? Reaching out into the community to meet clients at their specific places of challenge and work through them is a HUGE benefit of mobile therapy. Some children, because of their motor programming difficulties, may have trouble applying gains made in clinic therapy sessions into a real world situation. The clinic session has worked on the strength, the balance, and coordination of the task but because it is a new environment, the child struggles to perform it at their church which is a goal discussed between therapist and family. Luckily a mobile therapist is able to have one, two or five sessions at the church (however many it takes!) and is able to meet that goal! Now your child is independent in entering the church and no longer needs your assistance to get to their class! What a HUGE confidence boost for that child!

“Having this session at home was just so easy! Thank you”

After the age of three, the state no longer provides therapy in an in-home setting and moves to school-based care. Unfortunately for some kids this means they either stop getting state provided therapy or their goals are only made for very school specific things for them to be able to achieve their education. While this is GREAT, and kids really need these services in school, sometimes it is not enough. Having only school-based education goals misses out on 2/3 of a child’s life: home goals and play goals! Children are meant to PLAY no matter their functional level and it is so IMPORTANT to their development to engage in creative play, social play, and gross motor play (where a PT comes in!). Gross motor play develops their strength, bilateral integration, range of motion, balance, coordination, and vestibular system. Proficient gross motor play leads to better social play with team sports or team activities such as tag. Better ball skills allows your child to participate in kickball with their class without feeling embarrassed. Better strength and balance allows them to climb onto a playground and race for the slide with friends. While there are only a few positive studies that have been done to see how treatment of coordination and gross motor skills could leads to better social and education performance. There ARE studies that show the negative effect or interplay between low gross motor and coordination skills and difficulty with social engagement or school performance.

Home sessions allow for parents to be more compliant with their child’s plan of care. Last minute cancels and reschedules are far less common with at-home care. Secondary to an increased treatment rate in a comfortable environment, children reach their goals faster and hopefully start improving in their other realms of development mentioned above!

Photo by Johan Bos from Pexels

525,600 minutes…How do you measure a year?

Carryover and compliance with home programs is IMPERATIVE to meeting goals and progress in therapy for each child that needs intervention! Empowering parents to perform therapy at home themselves between sessions is the most important piece of helping a child improve. They see me once a week, for an hour at the most. There are 167 more hours in the week where a child and a parent could be working together on things through play to TRULY CHANGE that child’s performance and function. Many parents struggle with taking exercises from session - using clinic toys and equipment - and applying it to their home environment, toys, and furniture. Some parents are amazingly CREATIVE and other’s aren’t! And that is FINE. But having a therapist come in with their “therapist eyeballs” and make your mattress into a trampoline, flower beds into a balance beam, or couch into a mountain (with permission of course!) helps parents see the potential in the things they already own. I have so many parents ask… “should I buy that for my child??” when using a clinic specific piece of equipment. While they COULD and sometimes have to depending on the equipment, why spend the money on something used nearly never in a home environment? Most of the time something they already own could be modified to perform the same task. Home program compliance and confidence from the parents is a huge benefit of the mobile therapist.

The world is our oyster!

Think you want to do a session at dance class? What about an indoor flying center? How about a National Park?! The world is most certainly our oyster: Where your child is struggling, Where they would like to be successful, Where they want to have fun with their peers! In the short time Milestone has been open I have already gone and done some AMAZING things with my clients, supported them in tasks I never thought I would be getting into! I work closely with their instructors to help modify activities to help the child be successful or overcome musculoskeletal limitations. While therapy needs to focus on the functional most of the time, working on something highly motivation to the child can actually dramatically improve their participation in sessions outside of the motivating activity especially if that activity has some carryover into functional goals already laid out for them.

An anecdotal case where I had a client who’s depression surrounding his condition dramatically improved with the addition of indoor flying lessons. After starting these lessons there was also a dramatic improvement in participation in sessions as well as huge gains in progress toward functional self-care goals. I worked closely with instructors to work on modifying moves in the tunnel and working on exercises to promote his tunnel work. Treating the WHOLE child has meant vast increases in performance in many realms and true change in function and quality of life. The mobile therapist can help motivate your child to new heights not only functionally but emotionally as well!

Benefits of a Mobile Therapist are far reaching. A child is not only the impairments seen in clinic, or in school, or at home, or the community they are a sum of ALL of these things. Mobile therapy seeks to treat the child and family as a whole! Empowering parents with more confidence in home program compliance and assisting their child toward their goals. Uplifting children to reach new goals and try things they have only dreamed of (in a safe manner!).

And so we go…On the Road Again!

"Idiopathic" Toe Walking - The Perpetual Ballerina

At 2 years old, your adorable “ballerina” is cute now but when she is 8 and STILL tip-toe walking and now complaining about pain in her feet AND legs it won’t be so cute anymore. This blog post covers Toe Walking, its causes and how its NOT idiopathic, the importance of early intervention, and issues that will arise as your child ages if its never corrected.

Your little ballerina is cute now…

They will not “Just grow out of it”

Toe walking, tip-toe walking or equinus gait pattern as its referred to in the medical community is not an un-common condition in pediatrics and their walking development. Typically seen upon the onset of walking - these kiddos are typically destined to a life of being the perpetual “ballerina” if it isn’t corrected at a young age. A popular opinion from pediatricians and family care doctors is “oh they will just grow out of it.” The sad fact is most do not and because intervention was missed when they were little, many never fully recover or take months to years to begin walking normally without issue even with pediatric physical therapy intervention. While toe walking is never an easy condition to treat it is much easier to treat a child that has only been toe walking for 6 months or a year as compared to 7-10 years. The movement habits are far more engrained and the musculoskeletal changes that have occurred are often to some degree un-reversible.

I think my kid is a toe walker…

Toe walking is a gait pattern where at initial strike of the ground a child hits on the ball of their feet and their heels never touch the ground throughout the cycle. This results in a Toe-toe gait pattern as opposed to the typical heel-toe gait pattern of normal walking. Toe walking is categorized by a child that walks on his/her toes for over 50% of their steps during the day, stands “still” on his/her toes, and/or is unable to bring heels to ground even when asked by an adult. Toe walking typically presents within the first 0-6 months after a child begins walking upright either cruising or independently walking. (*A typically developing gait pattern demonstrates a consistent heel strike by 18 months of age or 22.6 weeks after onset of independent gait!) Sometimes toe walking can arise during later years between 3-5 years of age if its more associated with a sensory impairment. In the beginning, most toe walkers are “intermittent” toe walkers walking between 25-50% of steps on their toes but as they develop, this will increase to nearly 100%. If your 18+month old is spending a majority of his/her time on their toes when upright, it is cause for some concern and to bring it up with your pediatrician so they can be monitored or potentially referred. By 3 years of age and they are still toe walking, it is cause for definite concern and it is time for a referral for physical therapy evaluation.

Some toe walkers can “self correct” and walk “normally” if they are thinking about it but as soon as they are distracted immediately rise to their toes again. Some other characteristics of toe walkers include an inability to be “still” when standing- their feet are constantly moving even if their body isn’t, walking VERY quickly or nearly running every where they go, and older toe walkers may have issues with gross motor coordination tasks that challenge balance or single limb strength.

A consistent heel strike and arm swing should be present in typical walking by 3 years of age…

Toe walking IS a symptom of something greater

Toe walking can have a variety of causes. A thorough exam will rule out sinister neurological causes such as Cerebral Palsy, Muscular Dystrophy, or others. But once these causes are eliminated your child doesn’t just have an “idiopathic” version of toe walking. Idiopathic refers to a condition with no known cause. And let me stress KNOWN! Just because we don’t KNOW what is causing your child’s toe walking, doesn’t mean it doesn’t have a cause, we just need to test to find your child’s cause! Some underlying causes of “idiopathic” toe walking include: vision issues, hypo/hyper sensory issues, poor vestibular development, congenitally/acquired tightened achilles tendon, flat feet, and poor core strength to name a few. Your child could have just one or a few of these underlying causes that are contributing to the SYMPTOM of toe walking.

Many case-studies regarding toe walking often come up short on the goals originally set and pediatric therapists everywhere immediately cringe when they hear they have a toe walker on their schedule. But this is because if you don’t address the underlying CAUSE of the toe walking, no amount of stretching, retraining, or orthotics is going to change that child’s walking behavior. And I will admit, I WAS that therapist in the beginning - wasn’t getting the results I wanted with these kids and I knew something else had to be contributing to their gait patterns - at the time I just didn’t know what I could screen to figure it out though! After years of experience and courses later I now have a much better grip on determining each child’s exact recipe to getting better.

Early Intervention is KEY

At some point with these blogs I am going to sound like a broken record… But early intervention IS key! The longer a child toe walks, the more negative changes can occur in their muscles and developing skeleton. Their poor motor patterns become more engrained in their system (bad habits essentially). Thus leading to increased difficulty in making a full recovery for that kiddo! A young toe walker - I am talking 2-3 years old or younger - has not developed stiff joints or muscles, has not developed engrained motor patterns and bad habits, and has an easy potential to reverse the entire trend with some physical therapy intervention, addressing underlying causes, and potentially special braces to promote typical walking patterns.

Now, not just any physical therapist is going to do! I highly recommend seeking a pediatric physical therapist who has experience with and the express desire to work with toe walkers. Not only will a pediatric provider be able to engage your child in therapy better, but will have more drive to research and access to intervention tools that are specific to toe walkers. I am not saying that a traditional orthopedic physical therapy provider won’t be able to help your child in some way but likely they will not have read the research papers, taken the courses, or have the interest in treating the complexities of pediatric toe walking (returning to that idea of all they need is stretched out right?").

How bad could it really be if I don’t get my child treated?? They are a kid after all!

Alright, so your doctor said your child will grow out of it and you are inclined to believe them. Before you make your final decision please heed a few warnings… As a toe walker ages several things happen to their developing musculoskeletal system.

1. The skeletal structure in their feet changes. Without getting too anatomical, a bone called the navicular (our arch bone basically) gets really big because of the stresses the feet are taking and a bone called the calcaneus (our heel bone) and heel fat pad does not develop because weight is not being bore through them. This leads to eventual difficulty with heel-toe pattern by limiting the heels ability to absorb shock and the navicular will potentially block adequate dorsiflexion for walking.

2. Their core gets REALLY weak. By walking in the way they do, their gluteal muscles do not fire, their belly muscles turn off, and they end up utilizing ligaments to hold themselves in standing- which doesn’t work well by the way. And they use gravity to move- the traditional “Leaning Tower of Pisa” look that toe walkers display as their trunk becomes more and more forward of their feet.

3. They could get PAIN. Many older toe walkers I treat complain about foot or lower leg pain or fatigue by the end of the day, end of playing, or walking for long distances. Because of the altered gait mechanics, toe walkers send abnormal stresses up their feet and legs resulting in pain or muscle fatigue from improper biomechanical use.

4. Their muscles get really tight EVERYWHERE. Think this is just a foot problem?? Nope. Not only does their calf muscle become tight, so does their hamstrings, their hips, their lower back… And a tight muscle is a WEAK muscle.

5. Their balance is horrible. Depending on how bad their range of motion is, some toe walkers are unable to place their heel on the ground to balance on one foot. Imagine trying to balance on one foot with your heel in the air? You’d have to have the skills of a ballerina to accomplish that… and your 5 year old does not. Even if they can get their heel on the ground many have not developed the appropriate foot and ankle strategies to maintain their balance appropriately.

6. Their gross motor and coordination skills can become delayed. When they are little, many toe walkers can “hide” their issues with gross motor development. But as a toe walker ages, the increasing tightness and weakness present throughout their system starts to truly reduce their ability to run as fast, jump as far, or participate in typical childhood activities as well as their peers. Depending on research you read, this could have detrimental impact on social development and even education.

Trust me when I say a few months of intervention at an early age are far easier on your child, you as the parent, and your wallet compared to potential years of intervention in an older child. Now if your child IS the older toe walker- don’t beat yourself up! But get them into PT so they can be helped and hopefully avoid many of the issues named above. The key to success in toe walking management is early intervention and individualized care to your child’s underlying cause for toe walking. I promise your child won’t have to be a ballerina forever…unless they choose to be!

Torticollis...Not just a cute tilted head

Congenital Muscular Torticollis is a condition where your baby has limited neck range of motion. Most commonly this causes them to only hold their head tilted to one side with their head rotated in the opposite direction. The sternocleidomastoid muscle (SCM) is the most attributed to the head position and typically the most constricted muscle when treatment is performed— sometimes a fibrotic mass can also be felt within the muscle. Torticollis is the third most common musculoskeletal condition in infants and affects 0.3% to 1.9% of newborns.  Most recently, there has been an increase in incidence associated with the beginning of the Back to Sleep Campaign, which has saved countless infants from Sudden Infant Death Syndrome (SIDS). However, the campaign led parents to decrease the amount of time spent on an infant's stomach as well as an increase in time spent in carrier devices with weight on the back of their head. 

The Sternocleidomastoid Muscle is most commonly affected in Torticollis.

Did I do THIS to my Baby?? (I promise you did not!)

The exact causes of Torticollis are unknown but there are several theories on why an infant develops the condition (none of which you could have done anything about so don't beat yourself up!). Pre-birth factors include decreased space in the uterus (from maternal frame size, increased fetal size, or uterine abnormalities), decreased fetal movement, multiple birth (twins), and a breeched birth position. During birth factors are specifically trauma to the SCM muscle (lack of oxygen or bleeding) causing the infant to favor that side allowing tightness to develop. Post-birth causes include positional plagiocephaly (flattening of the head) or too much time spent in carrier devices. This type of Torticollis traditionally develops secondary to a normal lack of head control in the first months of life and a dependency on the shape of the head for their head positioning. (But more on plagiocephaly later!)

An infant demonstrating a left Torticollis typical presentation.

How do we know your baby HAS Torticollis you ask?

Torticollis is a traditionally a clinical diagnosis following observation, strength, and range of motion testing by your infant's doctor and pediatric physical therapist. X-ray's or MRI's are typically not performed unless the infant's case is severe or is not responded to traditional therapy. Sometimes an ultrasound is performed to visualize the SCM if a mass is present or to rule out hip dysplasia (unstable hip joint) which is associated with torticollis. 20% of infants with Torticollis develop hip dysplasia and your infant's doctor and PT will perform a clinical test to rule it out or recommend an US if the test is positive. 

Won't they just grow out of it? The answer is a resounding NO!

Torticollis doesn't just affect your infant's head and neck but has a global effect on their development. Treatment of torticollis is important in prevention of gross motor delay and gross motor asymmetries early in development. Without treatment, as your child ages, they could develop difficulty in vestibular development (inner ear/balance), headaches, neck pain, and potentially development of scoliosis (abnormal curve of the spine) if torticollis is left untreated. 

A traditional torticollis exercise your physical therapist wound teach you.

What can I do to HELP my baby?

First and foremost, if you notice a change in your baby's head shape OR a preference for looking or keeping their head tilted to one direction, bring it up with your Pediatrician. Voice your concerns. Doctors are getting better about early referrals, but torticollis is much easier and faster to treat if physical therapy is started prior to 2 months of age. Then once your referral is in hand, go to physical therapy and listen to your therapist! Torticollis is managed in the home. At Milestone, Dr. Megan serves as your guide to learn how YOU can help your baby. She teaches you stretching exercises, strengthening exercises, and gross motor activities throughout the treatment of your child. She will make sure you are as independent as possible in performing them in the home setting. Research is also showing that with torticollis MORE IS BETTER. The more stretching you can perform per day on your child the faster they will gain range and resolve their torticollis. One study even showed 100 stretches a day to be significantly more effective than 50 stretches a day.

 How long will my baby have Torticollis? 

Luckily if physical therapy is started within the first 6 months of life, an infant with torticollis typically resolves by 6 months of intervention at the longest, unless there are complications to care. Infants who start after 6 months may take 8-12 months of intervention depending on severity of the Torticollis and the asymmetries present in gross motor development. Timelines may differ if your infant has other co-morbidities/conditions to their health. 

This photo depicts two types of head shape deformities potentially seen in infants.

You mentioned that Plagio-thingy earlier... what's that?!

Plagiocephaly is the flattening of one side of an infant’s head seen commonly in children with torticollis. Plagiocephaly is caused by either intra-uterine positioning or post-birth positioning. This head shape will contribute to and exacerbate the symptoms of torticollis is left untreated. Plagiocephaly is easily treatable with conservative re-positioning if your infant is under 3 months of age or with a cranial orthosis (helmet) if greater than 3 months of age. Plagiocephaly does not typically improve without intervention if the child has reached the “head growth spurt” that occurs around 4-6 months of age. Their head will tend to grow larger but sustain the same shape.

If moderate to severe plagiocephaly is left untreated there can be medical repercussions that may develop including, but not limited to, jaw malocclusion, facial asymmetries, or challenges with fitting safely in a helmet for sports or bicycling riding later in life. If your baby has significant plagiocephaly, your therapist will refer you to an orthotist who specializes in producing cranial orthosis for infant to perform a full examination and make their official recommendation on whether or not your infant needs a helmet.

Don’t worry if your baby needs a helmet, these babies are the cutest things around!

Torticollis isn’t so scary after all…

So hopefully if your child has torticollis or you are concerned about it, you are feeling a little more at ease. Torticollis is easily treated. With a little hard work, dedication, and physical therapy intervention, your infant will be better in no time and you’ll just have a pile of cute tilted head photos to show from it… and who knows? Maybe your baby will be the next best internet Meme because of it!

5 Reasons Why Fee-for-Service Therapy is Better!!!

"Do you take my insurance?"...One of the first questions you ask any medical provider before your schedule your first visit... In Milestone's case, the answer is no, but this blog post is all about why our model delivers improved care, more personalized services, and will save you money in the long run. 

5 Reasons Why Fee-for-Service Therapy is better:

1. Cost Effective Care

• Even in an insurance based clinic, clients are responsible for co-pays and deductibles. These could run from $30 a visit to over $100 a visit for some of the highest deductible plans. These co-pays and deductibles are non-reimbursable by your medical insurance and are expected costs to you as the insured on top of what you pay each pay check. Additionally depending on what is billed each session, sessions fluctuate in price and coverage and the overall cost to the client is not up front, leaving the client feeling frustrated with a bill they didn't expect at the end of care. 
• In a fee-for-service model, all session prices are transparent, established up front, and do not fluctuate session to session. Based on the frequency of care and established plan of care length, a parent will be able to predict the cost of the therapy their child needs. Milestone does not believe in plans of care that "go on forever" and will determine meaningful goals and work toward those in an episode of care. Much of the time you can expect some reimbursement from your insurance provider for the out-of-network service or for the fees to be applied toward your out of pocket or deductible. We strongly recommend calling your insurance company to find out the process, find out if you need pre-authorization for therapy, and what the coverage might be. Milestone will work with parents who ask through the initial self-submission paperwork and will provide parents with a detailed invoice with the appropriate codes needed for reimbursement through their insurance company. Also, the sessions are able to be paid with your health savings account or flexible spending account if you have an insurance plan with that option. 

2. Improved Client-Therapist Relationship

• In insurance based clinics, many times the insurance companies dictate what they think to be appropriate frequency, appropriate services, and appropriate duration of care. Insurance companies may also dictate what they think to be an appropriate medical diagnosis for treatment and decide to not cover certain conditions that significantly affect your child's ability to function in the home and community. Many of these standards are set arbitrarily by individuals that have no experience with pediatric physical therapy and no knowledge of what is truly appropriate to address a client's deficits and meet their goals. Many times, providers will end up spending long hours attempting to get their reimbursement through insurance, and often, reimbursement is low or not provided. This takes away from valuable time the provider could be researching your child's condition, taking continuing education to improve their professional knowledge and skill, or working on other important services to provide clients. Other times administrators are hired to help facilitate the process which increases overhead costs resulting in the need to see more clients each day, decreasing one-on-one quality time with the therapist.
• Because Milestone is a fee-for-service model, Dr. McIntyre can develop an appropriate plan of care with appropriate length and frequency to meet the needs of the client. One-on-one quality time is provided with time for question and education sessions for the parent to carry over newly formed skills into the home/community. Services can also be offered in a variety of community settings including your home, the playground, gymnastics lessons, or other activity without worry of approval by the insurance company. As necessary, Dr. McIntyre can also engage in consultations with other professionals involved in your child's life, including teachers, coaches, and other health care providers to work on establishing a more complete plan of care to address all concerns for your child.

3. Accessibility 

• In insurance-based clinics, getting an appointment can sometimes take weeks, months, and or even a year before the next "opening" comes along. Many times clinics have to keep themselves this busy with decreased discharge rate in order to meet productivity standards set by their establishment. Without the ability to tailor their plans of care to specific needs of the client, many times progress is slower and carry over into the home or community is decreased. Providers are also unable to set aside time to have sessions in the community or consult with other necessary care providers secondary to their productivity standards and traditional insurance based approaches to care. Also, many providers are tied to the hospital with inconvenient hours that do no include before or after school/work hours to accommodate clients and parents. 
• Because Milestone is a fee-for-service clinic, Dr. McIntyre's case load is smaller and has more flexibility in her schedule. Dr. McIntyre is able to offer a wide variety of hours to accommodate a client's schedule. Dr. McIntyre can typically offer an initial evaluation with in a week of a parent calling. Milestone is a functional-based clinic with priorities set on helping your child engage as fully with the world as possible. Because of the fee-for-service model, Dr. McIntyre can also integrate sessions into the community without worry of productivity standards or the times the clinic is "open" and is then able to provide necessary care for your child to meet their goals.  Dr. McIntyre is also available by phone or by email to her clients throughout the week if there are concerns or questions and will go the extra mile to research topics and send informative information back to the parent in a timely manner.

4. All Clients Are Welcome

• In an insurance based clinic, after the initial evaluation, they may determine your child's needs are not medically based or necessary and therefore not coverable by insurance or a priority for care. Parents are left feeling frustrated that there is "something wrong" but because it is not seen as medically necessary, care is not always provided. In insurance based-clinics, clients may also be turned away if they have insurance that is not accepted by the clinic.  
• Because a fee-for-service clinic is not guided by insurance mandates, any client who is referred for gross motor concerns, if deficits are found, is a candidate for therapy at Milestone. With new research coming out in recent years regarding the importance of gross motor skills in the development of peer interaction, confidence, and even school performance, even the mildest gross motor and coordination delays are important to address as much as the most obvious delays are. Each child should be offered their best shot at functioning as optimally as possible in their world! No matter what your insurance, Milestone won't turn you away from care.*
• *In the case of individuals with Medicaid primary or secondary insurances, there are certain rules and regulations when it comes to providing covered services to Medicaid subscribers when not participating with Medicaid. At this time Milestone is not treating clients with Medicaid insurance coverage to protect both the client's and Milestone's interests. 

5. Monthly, Bi-annual, and Annual Check-Ups 

• This type of service is not typically something provided by insurance-based clinics as it does not follow the traditional model of physical therapy. Either clients are discharged after a set amount of visits and deemed "cured" or clients linger forever attending therapy once a week until the end of time because they fear they will be unable to get back into services if they do a take a break. But breaks and episodic care are important to both the child's attitude toward therapy, the family's and therapist's need for a break, and often allows the family/child to focus on other important aspects of their health and well-being. 
• As physical therapy has developed into a Doctoring profession and become the Movement and Mobility Experts in the health field, the need for check ups of some frequency has become of an ever increasing importance. As we strive to optimize the prevention of injury or in a child's case in the promotion of development, physical therapy has grow to fill this need. We see our family care doctors and even our chiropractors for annual check ups and tune ups... why wouldn't you also see your physical therapist for the same thing especially after you have become an established client? Catch an issue before it's a problem and decrease your health care utilization in the long run!! As of now, insurance companies do not cover this sort of service despite its importance in overall health care. At Milestone, every client that has completed their current episode of care will be scheduled for a check up visit 3-6 months afterward to make sure all goals are being sustained and new issues have not arisen, if all is going well the check ups continue in the same manner. This approach to a lifetime of care for children who will understandably need a lifetime of services makes sure each child is monitored for gross motor development and that intervention is delivered when most appropriate!  

Now, fee-for-service care is not for everybody, Dr. McIntyre understands this, finances have to be kept in consideration. She tries to keep her costs fair to the client and all costs are based on average current insurance reimbursements (in a perfect world where they actually pay you what they say they will!). For families that are looking for personal service, one-on-one quality attention and care both during your visit and in between visits, and the ability to integrate therapy into the community or home setting, this type of model can offer that and much more for you and your child.

Meet the Doctor!

Megan was born and raised in Nokesville, VA (about 1 hour East of Winchester). She spent her youth dancing ballet and various other dance forms, running XC and Track, and riding horses. Her first introduction to the field of physical therapy was after being thrown off her horse and injuring her back when she was in high school. After a course of 6 weeks of therapy, Megan was healed and had fallen in love with the profession. After that Megan set a goal of becoming a physical therapist "when she grew up!"

Megan with her husband, Nate.

Dr. Megan McIntyre, PT, DPT is the owner and currently sole practitioner of Milestone Pediatric Therapy.

Megan went on to attend Shenandoah University as a pre-admit physical therapy student. After three years of undergraduate work, Megan graduated with a degree in Kinesiology and a minor in Dance in 2012 and entered into the Doctor of Physical Therapy program at Shenandoah. During her education, Megan was introduced to pediatric physical therapy and became immediately curious about this subset of the profession. Megan had always had a love of working with children, from teaching dance during summer breaks to nannying, and she found a niche in working with children with disabilities. After several pediatric rotations, Megan decided she would continue to serve children with her career. 

After graduation in 2015, Megan began working with a company in Northern VA that supported her through expanding a pediatric program in an outpatient PT clinic. Here Megan gained confidence in her skills, working closely with several mentors and taking continuing education classes to further develop her knowledge. Megan built a very successful Torticollis intervention program, enhanced her ability to treat toe walking, and helped many children and families reach their goals and improve participation in activities of childhood and daily living. During this process, Megan continued treatment of typical orthopedic issues and has been able to incorporate ideas and skills from that area of PT into her treatment of pediatric conditions. 

While it broke Megan's heart to leave her clients behind, in early 2018, she set new goals and decided to begin working toward opening her own practice. Megan's vision was to bring her skills to an underserved area and improve the lives of children and families in need. Since Megan and her husband had lived in Winchester after graduating PT school together, Megan knew the area needed pediatric physical therapy services. Therefore, Winchester became the chosen location to build and open Milestone Pediatric Therapy!

Out for a hike at Buzzard Rock!

On a more personal note, Megan lives in Winchester with her husband, Nate, and their cat, Jackson. They hope to get a puppy one day! Megan loves to dance still- She and her husband take ballroom lessons together on a weekly basis! Megan also enjoys gardening, hiking, cross-stitching, and keeping herself in shape (so she can keep up with her clients!). You'll often find her set up in a coffee shop in town working or reading a book. Feel free to say HI if you ever run into her!

WE'RE OPEN!!!

Milestone Pediatric Therapy and Dr. Megan McIntyre are excited to announce they are NOW OPEN and accepting NEW patients! Please contact Dr. McIntyre to schedule an appointment today!

Dr. McIntyre has been busy marketing around Winchester, visiting pediatricians and family practices in order to introduce herself to the community and providers to families within the Winchester community.

Milestone's clinic is also complete with new toys and equipment to work on your child's gross motor skills. We want to thank Body Elite Physical Therapy and Karie Newman (owner) for providing us space to start up and begin offering pediatric physical therapy services! Milestone Pediatric Therapy will be operating out of the front room of Body Elite PT.

Now that Milestone is officially open Dr. McIntyre will be blogging and hopefully blogging about pediatric physical therapy topics at least twice a month so watch for new information to be coming out soon! Topics will include ways to work on core strength, gross motor development, balance training, and many, many more!