Friday, September 1, 2017

Benefits of Crawling! Why Crawling is Important in Motor Skill Development

Many parents get super excited when their kid starts walking - and who wouldn't be, what an exciting milestone to accomplish! Some parents even joke around saying that their kid will walk before they crawl. While some kids may skip crawling, crawling is extremely beneficial for development. This blog post talks about the benefits of crawling for motor development!

Crawling on hands and knees develops neck, shoulder, core, and leg muscle strength (Cimbiz 2005). Think of the last time you crawled on your hands and knees - do you think you'll be able to sustain that position for extended periods of time? Absolutely not! It requires a lot of work to crawl, which is why this form of mobility is so beneficial for infants. Visser et al (2010) found that children who crawl have more efficient pencil grasp, which could help in developing handwriting skills. Cimbiz et al (2005) found that child who don't crawl have lower stability in their hip joints as compared to their crawling counterparts, which can cause changes in movement patterns as they develop and possibly increase their chance for musculoskeletal issues in the future.

Crawling is also a great precursor to walking because it teaches the body how to weight shift laterally and move their arms and legs reciprocally. When we take a step forward with our right leg, we shift our weight over to the left so we can lift our right leg off the ground, then we swing our left arm forward. This reciprocal arm swing has been found to be the most efficient and economic way of walking, as it requires the least amount of energy to perform versus placing your arms at you side and holding them still (Collins 2009).

Along with strengthening, crawling allows children to explore their environment. Through this exploration, they figure out how to interact with objects around them and develop spatial awareness and proprioception. (Kubicek 2017; Schwarzer 2013). Bell et all (1996) even found that crawling can create more efficient pathways and connections in the brain!

In regards to crawling experience and how it reflects later motor skill development, McEwan et all (1991) found that noncrawlers demonstrated lower average and subtest-specific performance on selected measures of the Miller Assessment for Preschoolers, which is a screening tool that may be used by clinicians to identify preschool children who need further evaluation of sensory and/or motor skills. This shows that crawling helps to develop the sensory and motor systems of the body, therefore aiding in general motor skill development.

Here are some activities to help encourage your child to crawl!



1. Have them on hands and knees over your thigh. Holding the quadruped position (hands and knees) take a lot of core strength, and when our infants are learning how to move, just this position may be a challenge. Not only do you get to bond with your child through touch, but having your thigh as a place to rest their trunk will help them feel more comfortable being on their hands and knees. Make sure to place fun toys on the floor to get them to enjoy this position!


2. Place toys on a couch cushion and have them practice tolerating this modified quadruped position. If your hamstrings and low back aren't as flexible, let them play with their forearms on top of a couch cushion and rest their trunk over it while they're on their knees with their bottoms resting on their feet. You can sit behind them in a short kneel position and use your knees on the outside of their knees to help them to maintain this position.


3. Have them crawl over your legs to reach a toy. If they enjoy sitting, have them sitting next to you, sit with you leg out straight, and place the toy on the side of your leg opposite of the child. If the toy is motivating enough, they will transfer from sitting into quadruped and work hard to crawl over your leg to grab that toy.


4. Minimize/eliminate time in baby walkers, baby seats, and baby carriers. If you've read my previous post, The Dos and Don'ts of Promoting Independent Walking, you know that I am not a fan of baby walkers at all. Baby walkers are not only potentially dangerous for the baby, but they limit muscle development and time spent on the floor to practice crawling. Baby seats and baby carriers, while necessary for transportation, also decrease valuable experience and practice time for you little one to learn how to be mobile.


5. Don't force your child to crawl if they are letting you know that they're not ready. Respect the communication between you and your little one - if they are screaming their head off and are unable to console when you're trying to get them to crawl, they are letting you know that now is not the right time for them. Pressuring them to learn a skill they aren't ready for may actually slow the learning process.

In conclusion, every child is different and develops in their own way on their own time. Some children end up skipping crawling and are excellent walkers, some kids crawl for what seems like forever until they figure out they want to stand and walk. Remember that every child is unique and learns on their own timeframe. If you have concerns, contact your pediatrician or see your nearest pediatric physical therapist to see if there may be an underlying reason to delayed or atypical crawling patterns.

References:
- Bell MA, Fox NA. Crawling experience is related to changes in cortical organization during infancy: Evidence from EEG coherence. Developmental Psychobiology. 1996;29(7):551.
- Cimbiz A, Bayazit V. Effects of infant crawling experience on range of motion. Neurosciences. 2005;10(1):34.
- Collins, SH, Adamczyk, PG, Kuo, AD. Dynamic arm swinging in human walking. Proceedings of the Royal Society of London B: Biological Sciences. 2009;276(1673)3679-3688.
- Kubicek C, Jovanovic B, Schwarzer G. The relation between crawling and 9-month-old infants' visual prediction abilities in spatial object processing. Journal of Experimental Child Psychology. 2017;158:64.
- McEwan, MH, Dihoff, RE, Brosvic, G. M. Early infant crawling experience is reflected in later motor skill development. Perceptual and motor skills. 1991;72(1):75-79.
- Schwarzer G, Freitag C, Schum N. How crawling and manual object exploration are related to the mental rotation abilities of 9-month-old infants. Front Psychol. 2013;4(97).
- Visser MM, Franzsen D. The association of omitted crawling milestone with pencil grasp and control in five- and six-year-old children. South African Journal of Occupational Therapy. 2010;40(2).

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Monday, August 7, 2017

Why Injury Prevention is Crucial for Sports Participation in Children and Adolescents

Although I primarily focus on the developmental aspect of pediatric physical therapy, one of the big epidemics in the pediatric health care world right now that I continue to face constantly are youth sports injuries. This blog post is going to focus on youth sports injuries, how it affects kids of different genders and ages, and what we can do to prevent further injuries.

Children participating in competitive athletics have grown over the past few decades, which leads to specialization and competition in early childhood years. This specialization early on, combined with decreased physical ability and preparedness, predispose these children to significant injuries that will affect them physically and mentally. The intensity of youth sports predisposes these children to overuse injuries, such as patellofemoral knee pain, and more severe disabling injuries, such as ACL tears and concussions. Unfortunately, while awareness of these injuries may not be new news, we continue to see kids at a younger age be affected by these injuries, and some sports programs do not have a injury prevention program for their participants.

In a study comparing males versus females ages 5 to 17 in regards to pediatric sports injuries(1), girls tend to experience more overuse injuries compared to traumatic injuries, while the opposite is seen in boys. Girls tend to sustain more lower extremity and spine injuries as compared to their boy counterparts, while the boys tend to sustain more upper extremity injuries. Girls are three times more likely to experience patellofemoral pain than boys, while boys are two times more likely to experience osteochondritis dissecans and fractures as compared to girls. Something interesting to note from this study is that they found that the percentage of girls and boys who suffered an ACL injury was about equal...it's not just a girl's injury after all!
In another study comparing age groups of children 5 to 12 years old versus adolescents 13 to 17 years old(2), children in general tend to experience more traumatic, bony upper extremity injuries, while adolescents suffered more overuse soft tissue injuries to the chest, hip, pelvis and spine. Children seem to be diagnosed more commonly with fractures while adolescents were diagnoses with injuries such as ACL tears, meniscal injuries, and spondylolysis. Out of the children treated for spine injuries, most of them were female and due to overuse.

I'm not saying that we should pull all of our kids out of their sports and activities. I grew up playing almost every sport in the book and I'm so thankful that I did - I would not have had any interest in physical therapy if it hadn't been for my athletic upbringing! Instead, I want to push injury prevention programming. Every sports team, club, camp, and group should have some sort of program that promotes proprioceptive and plyometrics as part of an injury prevention program. But the challenge here is, how can we make it fun, especially for our younger population? Here are some exercises(3) I've disguised as "playtime activities" you can do to prevent injury!

- "Silly Jumps" aka Wall Jumps: Have them jump up and down on the toes with arms overhead, with the focus on soft, symmetrical landing. I'll play some music loudly so they jump up and down as high as they can, then I'll turn it down and show them my "quiet jumps" to the soft music. It's fun because they get to jump up and down super high when the music is loud, and it challenges their dynamic balance and reaction times because they have no idea when I'll turn the music down to switch to "quiet jumps!"

- "Fire Jumps" aka Jump tucks – For this one, they are jumping from a standing position and bringing the knees to chest, with the focus on soft knees and symmetrical landing. I'll have them run in place and when I yell "FIRE!" they will all jump where they are and try to bring their feet up as high as possible so their feet don't catch on fire!

- "Target Jumps" aka Standing Broad Jump – Have them bend their knees to around 90°, takeoff and land with both feet, and land with a 90° bend at knees, with the focus on soft, symmetrical landing and landing with knees bent. If you have multiple kids, you can make this into a contest and see who can jump to the target line (tape on the floor) without falling down. If they fall down, they are out of the game! Start the target line so that it's close so the kids can get comfortable with the motion. If all the kids make it past this line, move the line farther away. Keep doing this until they can't reach it at all.

- "Side Jumps" aka bounding in place – Have them jump off of one leg to the side and landing on the opposite leg, bend knee to 45-90° for takeoff and landing, with the focus on soft landing and landing with knee bent. Place fun targets on the ground for motivation!

- "Ballet Jumps" aka 180°s - This is where they perform a squat, then do a vertical squat jump with 180° rotation in the air, with the focus on soft, symmetrical landing and landing with knees bent. To add a more dynamic component to it, I'll make them wait until I say "JUMP!"and I'll speed up or slow down when I say it.

- "Bunny Hops" aka Double Leg Hops – This is a target jump/standing broad jump but done consecutive times forward, with the focus on soft, symmetrical landing and landing with knees bent. This can also be a race if you have multiple kids! Just make sure they know how to do it properly and with good form before they race :)

- "Side Hops" aka Single Leg Lateral Hop – Have them balance on one leg, then hop from side to side. The focus should be on minimal vertical displacement, soft landing and no collapsing of the knee in towards midline of body. If you see the knee collapsing in, do not perform this activity. This means that their hip musculature are not quite strong enough to handle the dynamic load of the single leg lateral hop. To progress this exercise, increase the distance traveled.

- Single Leg Forward Hop - Same as the Side Hop, but instead they are moving forward. The focus should be on minimal vertical displacement, soft landing and no collapsing of the knee in towards midline of body. If you see the knee collapsing in, do not perform this activity. This means that their hip musculature are not quite strong enough to handle the dynamic load of the single leg forward hop. To progress this exercise, increase the distance traveled.

References:
(1) Stracciolini, A., Casciano, R., Levey Friedman, H., Stein, C. J., Meehan III, W. P., & Micheli, L. J. (2014). Pediatric sports injuries: a comparison of males versus females. The American journal of sports medicine, 42(4), 965-972.
(2) Stracciolini, A., Casciano, R., Levey Friedman, H., Meehan III, W. P., & Micheli, L. J. (2013). Pediatric sports injuries: an age comparison of children versus adolescents. The American journal of sports medicine, 41(8), 1922-1929.
(3) Irmischer, B. S., Harris, C., Pfeiffer, R. P., DeBeliso, M. A., Adams, K. J., & Shea, K. G. (2004). Effects of a knee ligament injury prevention exercise program on impact forces in women. The Journal of Strength & Conditioning Research, 18(4), 703-707.

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Monday, May 22, 2017

Work That Booty! - Why Glute Activation is Important for Babies as well as Adults

As I begin to get more interested and read more about Neuro-Developmental Treatment for my little ones, a pattern I've noticed in Lois Bly's books(1) is that she emphasizes facilitation of the gluteus maximus (GM). I know that as an adult, we work on our glutes for injury prevention and to get a nice looking tush...but why are the glutes so important for our babies? This post will talk about the anatomy of the GM, describe the role the GM plays in for motor skill acquisition, and ways to promote GM facilitation during daily activities.

The GM is the biggest muscle of the posterior hip region, which allows it to perform powerful and big movements. The GM is attached proximally to the pelvis and tailbone (specifically the ilium, sacrum, and coccyx), is attached distally to the IT band and the femur (thigh bone), making it one of the major hip extensors of the human body. Hip extension is the backward motion of your thigh. As adults, we extend our hip when we roll over in bed, stand up from a chair, get out of a car, walk, run, jump and use stairs. If you're a gym goer, exercises to work the GM include squats, bridges, step ups, and kettlebell swings.

As our little ones learn to move and access their environment, they use hip extension for almost every movement. When they are laying their tummies, they learn to use their spinal and hip extensors to allow them to lift their head and neck to interact with their environment in front of them. When they become stronger with this movement, they can begin to roll, which requires a significant amount of extension to move against gravity. When they get the strength to get onto their hands and knees, they will use hip extension to begin to crawl, reach for support surfaces, and ultimately pull up into the standing position. When they are learning to stand independently, they will use their GM to maintain hip extension and an upright position in standing. When they begin to walk, hip extension will be important to allow them to propel themselves forward. When they fall to the ground, they will transfer from the floor into standing, and they will use their GM to extend themselves upright. As you can see, correct activation of the GM is crucial for the baby's development!

How can we promote GM activation in our little ones? Here is a list of common functional exercises I use to work out their little tushies!

1. Squatting to pick up toys while holding onto a support surface. If they still require support in standing, you can still work their GM while working on balance! With one hand on the support surface, play a toy at their feet and motivate them to reach for that toy. Their tiny bodies will not be able to reach for it without bending their knees, and although they will be able to use their upper body to assist, they will at least get some work in those hip extensors to help them return to standing. One of my favorite toys to promote squatting is the Get Rollin' Activity Table. Kids love to put the ball inside the hole in the middle and search for which leg of the table it ended up in, which ends up in them squatting to grab the ball!

2. Crawling/walking/ climbing up an incline. Think about the last time you walked up a steep hill or went on a hike - how badly were your glutes burning?! I tell almost all my parents to get their kids crawling or walking, depending on their motor ability, on any hill or incline you can find. Inclines target the hip extensors more than on a level surface because you need the power of the GM to propel you up and forward against gravity. Use a toy or parent/family member to motivate them to take on the challenge. From a small hill in the playground, to an incline ramp on the playground, the only way to go...is up! :)

3. Rotation in independent standing. Once kiddos are able to figure out how to stand on their own, the next added challenge is for them to turn their head and torso over their pelvis while remaining standing. Babies tend to live in the sagittal plane, that is, anything going in the forward/backward direction. Challenge their dynamic standing balance by having them move and work to the left and right and having them rotate their body over their legs, and they will automatically recruit their GM to allow them to maintain their upright standing position. This is where bubbles are my best friend! Blow bubbles in all directions around the kiddo and watch them figure out how to remain standing while trying to watch all these bubbles go in all directions - just make sure the ground around them is squishy and safe in case they lose their balance!

(1) My two personal favorites from Lois Bly: Motor Skills Acquisition in the First Year and Baby Treatment Based on NDT Principles.

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Wednesday, March 8, 2017

Dos and Don'ts of Promoting Independent Walking!

One of the biggest and most monumental milestones in a child's life is when they take their first steps. Walking allows kids to explore their environment and start to be more independent. Plus, it's super fun watching a child learn how to walk for the first time! I have created a list of DOS and DON'TS that I believe will help you as the parent or caregiver to get your child up and walking! (DISCLAIMER: This is an opinion post - any views or opinions represented in this blog are personal and belong solely to the blog owner and do not represent those of people, institutions or organizations that the owner may or may not be associated with in professional or personal capacity, unless explicitly stated)

#1: DO allow them to be barefoot!

There are two big reasons as to why I always take my kids' socks and shoes off for their PT session: 

1) Being barefoot gives their body the sensory input that they need to improve their proprioception. It allows them to figure out where their feet are in relation to the surface and in relation to their entire body, which in turn helps them learn balance and coordination.

2) Being barefoot allows babies to flex and improve the strength of their forefoot and toes as they learn to crawl, pull to stand, and cruise along furniture - this applies to when they get older and the learn how to walk as well!

Shoes don't give kids as much sensory input as they would receive when their barefoot and they definitely don't allow kids to flex their forefoot and toes. If you are taking your kid outdoors, make sure the shoes are low profile, light weight, soft-soled and flexible to allow for as much ankle and foot motion as possible.

#2: DON'T place you kid in a baby walker!
My biggest concern first and foremost is that it is a safety issue. The American Academy of Pediatrics have banned baby walkers in Canada and want the US to do so as well due to their high risk of injury from falls down stairs and allowing children to access dangerous household appliances and objects. Other than the safety issue, research shows that kids who spend time in baby walkers actually tend to walk later as compared to their peers who do not use a baby walker. Some reasons I don't like the baby walker are:

1) The baby walker does not allow them to see their feet and legs, which is crucial for them learning how to move their legs and step properly. Imagine trying to knit a sweater for the first time but not being able to see the yarn, needles, or your hands! Kids rely heavily on their visual system in their early years to learn how to maintain their balance, so by being able to see where they are stepping and where their feet are going helps them tremendously.

2) The baby walker does not allow them to perform other gross motor functions to get them to walking, such as crawling, pulling to stand, or stepping with support. It is a completely dependent piece of equipment that does not allow kids the opportunity to explore their environment as independently as possible.

3) It put babies in an unnatural standing position. Although it is very exciting to have your baby stand, place them in standing positions that are more functional, such as holding your hands or having them hold onto a support surface.

I understand that life can get busy and baby walkers seem like an easy alternative if you need to keep your kid contained for a few minutes. I would suggest placing your child in a playard or a gated baby-proofed room as better solutions to keep your kid safe while giving them opportunities to learn how to move independently.

#3: DO use push toys!
While baby walkers are limiting and don't allow them to see their feet move, a push toy allows them to see his legs and feet. This allows kids to practice standing and walking in a way that is more natural than the baby walker. While there are commercial push toys available for purchase, you can use regular household items such as a large box, hamper, rolling office chair, you name it - any of these will work!

However...

#4: DON'T force them to stand or walk!
If your child isn't ready to stand or take steps, forcing them to do so with a push toy or with your help can instill fear and anxiety in your baby. These feelings of animosity to may lead to delayed standing or walking. Instead of forcing them, motivate them!

In order to do so...

#5: DO place toys up high and at different heights! 
Children need to be motivated in order to move. If there is a toy they absolutely love, place them not only up high where they need to stand to reach them, but place them in different areas throughout the house. By placing them in different areas, you're giving your child the opportunity to access their toys in different ways to allow them to gain as much practice as possible in different situations. Think of it like hitting a baseball - you can practice as much as you want hitting the ball when it's pitched right down the middle, but when you get into the game, if they throw a curve ball or a slider, you'll have a much harder time hitting the ball since you only practiced one type of pitch!

Some of my favorite toys to encourage reaching up for toys and letting go of the support surface include bubbles, balloons, and balls big enough that require two hands. Bubbles and balloons are fun because they can be unpredictable and require dynamic balance as they move their eyes, rotate their head and trunk, and reach out with their arms for the bubbles and balloons. Having them reach and play with a bigger circumference ball encourages them to let go of the support surface and work on weight bearing through their legs.

#6: DON'T stop your baby from falling, as long as it is safe!
I like to compare the gait of a new walker to a drunken sailor on a ship during a storm - as they learn how to walk and gain the strength and balance required for the task, they may sway around, wobble back and forth, and occasionally take a spill...and this is okay! When they fall, their body learns that whatever they did to cause them to fall will not work, and in the future their body will work to figure out how to avoid the fall again. Kids learn not only about balance, but about their protective reactions to make sure they don't get hurt when they fall. The more they fall, the quicker these reactions become, making it safer for them to protect themselves when they fall again. And when they fall, don't make a big deal out of it. Although they may cry, it may be more because they are frustrated that they lost their balance versus getting hurt. Your tone of voice really will affect their personal reaction to the fall, so keep it light and happy as if that was meant to happen! Just make sure that your house is childproof by the time they start to take their first steps to allow them to really work on honing their newfound walking skills.

And since we're talking about falls...

#7: DO let them explore different surfaces!
Different surface changes will definitely challenge their balance, and the more surfaces you can expose them to, the better they will become at adapting to that change! At home, you can have you child walk over hardwood, tile, carpet, and even rugs that are slightly elevated. Take your child out to experience different settings! The playground, the beach, and other family's and friends' homes will expose your kid to not only different settings, but different challenges and a new place to explore!

#8: DON'T compare your baby’s development to other babies!
Remember that each child is unique in their own way, and that goes for their gross motor development. Even siblings may develop at different rates! Different factors play a role into when babies reach their milestones, such as body weight, personality, and exposure to the task. Babies that are born pre-mature or have been hospitalized for an extended period of time may not reach their milestones at the same time as babies born full-term. Don't forget that your baby loves you and whatever you do will impact how they feel, so continue to be their #1 fan no matter what.

#9: DO make her first steps into a big deal!
Your child took their first steps! CONGRATS! This is so exciting! Make sure you share your excitement with your baby. The more excited you are, the more excited they'll be, and the more they'll want to keep learning to take more step.

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Resources:
http://blog.dinopt.com/independent-walking-kids/
http://www.bmj.com/content/324/7352/1494
https://consults.blogs.nytimes.com/2010/02/22/the-dangers-of-baby-walkers/?_r=0
https://kendrapedpt.com/
http://www.wikihow.com/Teach-Your-Baby-to-Walk

Friday, January 6, 2017

Strength and Power Training for Kiddos with Poor Coordination!

When we PTs see a clumsy or uncoordinated kiddo, one of the first thoughts we think is “That kid can use some balance training!” or “They could benefit from functional activity practice!” What current evidence based research is finding is that strength and power training can be just as helpful if not MORE helpful than functional movement training!

Our muscles and our body learn through experience. Some kiddos who have difficulty with coordinated movements may be having a hard time using past movement experiences to predict the requirements for future movements.(2) According to Menz et al, “Because daily function requires complex movements, repeated practice requiring control of multiple degrees of freedom, as found in activity-level intervention, may not be effective at decreasing compensatory strategies and improving feedforward control.” What this means is that training functional tasks may be too challenging for these kiddos who have difficulty with coordinated movements.

Strength training that consists of multiple repetitions of isolated, simple joint movements can help a kiddo’s motor learning at the beginning stages prior to progressing to more functional and complex skills. This blocked practice will help the child’s ability to plan their movements due to the improved neural pathways and motor unit recruitment for the muscles groups needed for the task.

While Fong et al suggested that each exercise be performed as 4 sets of 10 reps each at 70% of their one repetition max and Menz et al suggested that each exercise be performed as 3 sets of 30 reps and increase weight by 1 lb until they are unable to complete the exercise, the common denominator between these two studies is that they require multiple repetitions. In my own practice, I find it challenging with some kids to have them attend to a set for that long, and I end up doing 20 sets of 5 reps! While this may not be the protocol according to these studies, what I find is that this is just as beneficial because these kiddos are getting the exposure and experience that they need. Remember: multiple repetitions equal more practice!

Here are some of the strength training exercises found to be beneficial according to Menz et al and Fong et al:
  • Squatting

  • Bridging

  • Heel raises
  • Leg Press - hold onto both ends of the Theraband while the middle of it is placed under your foot
  • Hip abduction - tie a Theraband into a circle and place them around the ankles

  • Hip flexion - tie a Theraband into a circle and place one end on the bottom of the resting foot and the other end at the top of the active foot

  • Prone knee flexion - tie a Theraband to a table leg and tie the other end around your ankle

  • Knee extension - tie a Theraband around a table leg and tie the other area around your ankle

  • Ankle dorsiflexion using Theraband

  • Shoulder extension using Theraband

  • Scapular retraction using Theraband

It is important to note that these exercises were from only two studies based off a randomized clinical trial and one case study. Also remember that every child is different. Not all exercises may be beneficial for your kiddo! My hopes are that this list of exercises just gives you an idea of something else to try if balance and functional training are not showing significant improvements in your child’s balance and coordination.

Resources:
Fong SM, Guo X, et al. (2016) Functional Movement-Power Training for children with Developmental Coordination Disorder: a randomized controlled trial. Medicine, 95(16).
Menz, SM, Hatten, K, Grant-Beuttler, M. (2013). Strength training for a child with suspected developmental coordination disorder. Pediatric Physical Therapy, 25(2), 214-223.

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Wednesday, December 14, 2016

Cerebral Palsy and Rehabilitation 101

Cerebral palsy (CP) is an umbrella term that refers to a group of disorders affecting a person's movement. Although it is typically described by impairment of motor function and it primarily affects body movement and muscle coordination, CP is actually caused by brain damage. This brain damage is a non-progressive brain injury of the brain that occurs while a child’s brain is still developing — before birth, during birth, or immediately after birth.

CP affects body movement, muscle control, muscle coordination, muscle tone, reflex, posture and balance, along with fine motor skills, gross motor skills and oral motor functioning. Other impairments may include intellectual impairment, seizures, and vision or hearing impairments.

What makes CP such an umbrella term is that every case is unique to the individual. The type of movement dysfunction, the location and number of limbs involved, as well as the extent of impairment, will vary from one individual to another.

There are many ways to classify CP. Some examples include (but are not limited to):
  • Severity:
    • Mild – child can move without assistance; his or her daily activities are not limited.
    • Moderate – child will need braces, medications, and adaptive technology to accomplish daily activities.
    • Severe – child will require a wheelchair and will have significant challenges in accomplishing daily activities.
    • No CP – child has CP signs, but the impairment was acquired after completion of brain development
  • Topographical:
    • Monoplegia/monoparesis - one limb is affected
    • Hemiplegia/hemiparesis- arm and leg on one side of the body are affected.
    • Diplegia/diparesis - usually indicates the legs are affected more than the arms; primarily affects the lower body,
    • Quadriplegia/quadriparesis - all four limbs are involved
  • Motor Function:
    • Spastic Cerebral Palsy is characterized by increased muscle tone.
    • Non-spastic Cerebral Palsy will exhibit decreased or fluctuating muscle tone.
      • Ataxic/ataxia: affects coordinated movements, balance, posture, walking ability, eye movements, depth perceptions and fine motor skills requiring coordination of the eyes and hands such as writing.
      • Dyskinetic displays as involuntary movements. Athetoid is especially noticable in the arms, legs, and hands. Dystonia/Dystonic is accompanied by an abnormal, sustained posture and affect the trunk muscles more than the limbs.
Rehabilitation will play an important role in coordinating the care of these often very involved patients. Physical, occupational, and speech therapy are available to help with many aspects of care, including, but not limited to, those relating to spasticity management, activities of daily living, communication, and much more.

Physical therapy (PT) will teach the child along with the parents and caregivers exercises and activities that are necessary to help the child reach his or her full potential and improve function. Postural and motor control training is very important and will be a huge focus during PT. Daily range-of-motion exercises are important to prevent or delay contractures that are secondary to spasticity and to maintain the mobility of joints and soft tissues. To improve strength, PT will prescribe and teach progressive resistance exercises to improve function. PTs may refer the child to an orthotist to prescribe bracing to help improve posture and positioning. Some PTs may utilize Kinesio Taping to help in reeducating muscles for stretching and strengthening.

Occupational Therapy (OT) will focus on activities of daily living, such as feeding, dressing, toileting, grooming, and transfers, along with focus on the upper extremity. The goal typically is for the child to function as independently as possible with or without the use of adaptive equipment. Activity-based interventions such as modified constraint-induced movement therapy (mCIMT) and bimanual intensive rehabilitation training (IRP) can be utilized to improve the child’s ability to use the affected extremity and improve independence with self care. Some OTs who are trained in feeding can help with any feeding difficulties that the child may have.

Speech Therapy (ST) will play a big role in helping to improve swallowing and communication. Many children with dyskinetic cerebral palsy and some with spastic cerebral palsy have involvement of the face and oropharynx, causing dysphagia, drooling, and dysarthria. ST may also recommend and teach the child how to use augmentative communication devices if they have some motor control and adequate cognitive skills. Some Speech Language Pathologists (SLP) who are trained in feeding can help with any feeding difficulties that the child may have.

Remember that incorporating play into all of a child's therapies is important. Just like with all of our children that we treat, therapy should be fun, not work! Therapists, parents and caregivers should seek fun and creative ways to motivate children, especially those who have a decreased ability to explore their own environment.

References:
Rehabilitation and Cerebral Palsy (Christine Thorogood, MD, 2013): http://emedicine.medscape.com/article/310740-overview
Types of Cerebral Palsy: http://www.cerebralpalsy.org/about-cerebral-palsy/types-and-forms

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Wednesday, November 30, 2016

Clumsy kiddo? Try PT for Balance Training!

Lately I have been evaluating a ton of kiddos who parents say their biggest concern is their child's clumsiness. These kids tend to trip over their own feet, stumble over surface changes, and have difficulty going up and down the stairs safely. While poor balance can be seen in children with diagnoses such as cerebral palsy and Down syndrome, it can also present itself without an official diagnoses.

What many parents don't know is that physical therapy can help with balance training! PT isn't just for children with developmental delays - as Physical Therapists, we are trained to improve or restore mobility, and balance training is one of our expertises!

Earlier this year, Fong et al published a study and found that a specific functional movement–power training program was effective in the enhancement of balance strategies and neuromuscular performance in children with developmental coordination disorder (DCD). It also appears to be effective as a stand-alone intervention designed to improve balance strategies, postural stability, and leg muscle performance. Even if your child does not have a diagnosis of DCD, these exercises can still be taught to your kiddo to help them improve their balance!

Here are the functional movement exercises from that study that you can use with your kiddos who are having trouble balancing:

- Standing balance on a stability trainer! My personal favorite is the dynadisc, but you can also use a BOSU or a rocker board as well. This will help to train bipedal static balance and proprioception. Have them throw and catch a ball or reach for objects around them for a dynamic challenge!


- One-leg balance on the ground! As simple as this exercise is, single leg balance helps to train unilateral static balance and proprioception. When we walk, we spend 40% of the time in swing phase, which means that we are only on one foot during this time, which makes working on single leg balance important for our daily mobility! Once they have mastered this, progress to one-leg balance on a stability trainer.


- Walk along a straight line with heels raised to train dynamic balance and coordination! Progress to heel-to-toe walk along a straight line to facilitate dynamic coordinated muscle contractions in the limbs and trunk.


- Double-leg jump forward! Jumping helps to train dynamic balance and coordination. Progress to single-leg hop forward - aka HOPSCOTCH! This also will help to strengthen the hip and knee extensors and calf muscles. 


- Walk and balance a ball on a plate simultaneously - you can have them play waiter/waitress! This exercises helps to train dynamic balance and coordination!

 

These next sets of exercises are part of the power training program. Have them perform 4 sets of 10 of each of these exercises to improve lower limb muscle strength, power, and contraction speed.

- Squats! You can have them hold onto heavier objects and toys as they progress to make an added strength challenge.


- Hip flexion in supported standing! Have them pretend that they are marching like a soldier. You can use ankle weights or a Theraband for an added strength challenge. Have them unsupported for an added balance challenge! 


- Knee extension in sitting! Just like the hip flexion exercise, you can also use ankle weight or a Theraband for an added strength challenge. To make this exercise more fun, you can have them kick a ball or a balloon!

- Hamstring curls while lying on their stomach, using ankle weights or a Theraband!


- Ankle dorsiflexion! My favorite way to do this exercise is have them sitting on the floor and cue them to "bring their toes towards their nose" while pulling the Theraband.


- Seated calf raises! If this is too easy, have them perform it in standing! Unsupported standing will also be an added balance challenge.


References:

Fong, S. S., Guo, X., Cheng, Y. T., Liu, K. P., Tsang, W. W., Yam, T. T., ... & Macfarlane, D. J. (2016). A Novel Balance Training Program for Children With Developmental Coordination Disorder: A Randomized Controlled Trial. Medicine, 95(16).

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.