Wednesday, October 10, 2018

Toys That Promote Development...and Toys That Don't!

The holidays are approaching! Halloween is coming up, then soon after it will be Thanksgiving, and then before we know it Hanukkah and Christmas will be here! If you're someone who plans ahead like myself, you are probably already making lists on your Amazon account of what toys and gifts to buy your loved ones. With this in mind, I decided to make a list of toys that I love to promote motor development, alongside with the toys that I don't love.

Recently in my practice I have been getting many referrals for children with no diagnosis other than "Gross Motor Delay." When I gather my subjective data for these kiddos, the parents talk about how their child is not yet crawling or walking. When I dig a little deeper, I find that the children are not having as much "explorational" play - that is, they are not using their body to move during play. With the craziness of life, many parents and caregivers opt to what I call "crate toys" to place their baby in for extended periods of time so that they can go about their business while the child is happy and entertained.

Remember that floor playtime is CRUCIAL for development. Play allows children to learn about their bodies, help the brain organize itself, improve cognitive growth, and much more. I understand that life can get busy, and if you are home alone with the baby and the only safe place to put your child is a "crate toy" while you run to pour yourself another cup of coffee or go to the bathroom, that is totally fine. However, the more time these children are spent in the "crates," that is time taken away from them to learn how their body moves during free play on the floor.

Here is a list of my most favorite and least favorite toys for development!

YES: Playpen/Pack 'n Play

Playpens provide a safe little area for your child to play and learn! If you are going to another person's house and you know that their home may not be baby proof, bringing along a playpen will not only allow your child to experience more unstructured play, but it will make you feel comfortable knowing that your child is safe.

NO: Bumbo Seat
Image result for bumbo seat
The Bumbo seat is severely restricting and limits crucial spontaneous movements of the trunk, arms and legs. Take a look at this kiddo in the picture - he can't move his legs or his arms! If he spends too much time in this seat, he will not learn how to move his arms and legs and he will not learn how to engage his core to allow him to sit upright and independently.
Research shows that when infants are in positioning devices, their leg movements are significantly reduced as compared to having no device at all (Jiang 2016). This is important because babies and children learn from experiences, so we want to give them as many opportunities as possible to experience movement!

YES: Boppy Pillow
Image result for boppy pillow
The Boppy pillow has so many wonderful uses throughout the first few months of your child's life! It allows both you and the baby to be more comfortable during nursing and bottle feeding. In between feedings, it's a great way to keep the baby propped up while they digest. As they get older, some babies prefer to do tummy time on the Boppy as it makes it easier for them to lift their head up against gravity. It also allows them to learn how to sit and use their trunk and core musculature to maintain upright - and if they tip over, they get to land in the soft cushion of the Boppy!

NO: ExerSaucer

Similar to the Bumbo seat, this type of toy restricts movement, especially of the trunk and ankles. Although the baby can move his arms, he will have difficulty rotating his trunk to fully appreciate exploring his surroundings.
Research shows that too much time spent in the Exersaucer causes restrictions of ankle range of motion, poor trunk control, decreased trunk rotation, and inappropriate movement patterns, all that effect their ability to achieve their gross motor milestones (Lenke 2003).

YES: Play Table

Play tables are a great motivation to get our kids up into standing and bearing weight through their legs! Once they are sitting independently and crawling, using a play table to encourage them to pull to stand and play in standing is highly recommended. The play table offers adequate support for them to lean and hold on to maintain their balance while offering fun motivation to maintain this position.

NO: Baby Walker
Just like the Exersaucer, the baby walker restricts movement of the trunk and blocks the baby from being able to see his feet, which is crucial for development of higher motor skills to be able to see where his legs are and how they are moving. I tell parents imagine never playing golf before, then being handed a club while being blindfolded and then telling you to play golf - think of how hard that is! While some parents get excited that their child is "walking" in the baby walker, because they can't see their feet they are not receiving the proper visual and proprioceptive input for their body to learn the proper movement patterns, which leads to abnormal movement patterns and delays in walking.
An old study that is often cited found that children who spent more time in baby walkers showed delays in the onset of crawling compared to children who spent less time in the baby walkers, concluding that too much time in this device can also delay other motor skills as well (Crouchman 1986).

YES: Push Toy
Push toys are a great way to get kids to practice walking! It allows them to practice their upright mobility with an unstable surface, allowing them to rely on anticipatory balance reactions to maintain their standing position. Plus, it's less pressure on your back if you are constantly trying to walk with them holding onto their hands!
However: make sure your child is ready to walk! If your child is not yet sitting or crawling independently, they are not ready to walk! In fact, using this toy too early can cause abnormal movement patterns which will in turn cause them to have a delay in their walking ability.

NO: Hanging Jumper Toy

Image result for hanging baby jumper
Very similar to the baby walker and the Exersaucer, this device restricts movement of the trunk and pelvis and does not allow them to see their feet, which as we know is crucial for development of higher motor skills and leads to abnormal movement patterns. While some parents think the baby is learning to "jump" in these toys, the abnormal movements patterns that they learn in these devices are incorrect in how to actually jump. I also like to tell parens that the average age for children to jump is 2 years old, so a baby should not be jumping at this point in their development.
Abbott et al (2001) found statistically significant correlations between total equipment use of multiple types of "crates" and infant motor development. The infants in this study, all around 8 months of age, that had increased equipment use scored lower on the Alberta Infant Motor Scale, or AIMS, which is a commonly used standardized tests to look at infant motor development from 0-18 months old.

YES: Baby Carriers

These baby carriers are especially great for children with Torticollis and Plagiocephaly. These allow for the baby to have less weight placed onto the backs of their soft skulls, therefore preventing any further skull malformation. If your child tends to look one way, especially in the car seat, this baby carrier allows for you to physically move their head and maintain it to their non-preferred side so that they can develop symmetrical range of motion. Plus, you get to be closer to your baby which is an excellent form of bonding between you two!

NO: Baby Swing

Graco Simple Sway Baby Swing, Abbington, One Size
Speaking of Torticollis and Plagiocephaly, I do not recommend the baby swing as it can further increase the severity of your baby's head shape. With the increase of families using carries such as the baby swing, extended use of car seats, etc., we are finding that more and more babies are being diagnoses with Plagiocephaly and require cranial orthoses to manage.
A research study from Littlefield et al (2003) found that out of their sample size of 636 babies over a three year span, over 25% of them spent 1.5 to 4 hrs, roughly 15% spent more than 4 hrs/day in these devices, and 5.7% slept in one of these device. They found that these babies often developed increased abnormal head shape as compared to their counterparts who spent less than 1.5 hours a day in these devices.

Please note that "normal use of car seats, carriers, swings and bouncy seats is not a concern; however, caution is warranted for infants who spend extended periods of time in these devices." (Littlefield 2003). So please don't feel like you have to say no to gifts that you receive from loved one if they are on my "No" list! Just make sure that your baby is not spending excessive time in these devices and that you continue to promote independent play :)

If you have any concerns about toys and your child's development, reach out to a Pediatric Physical Therapist!

- Crouchman, M. (1986). The effects of babywalkers on early locomotor development. Developmental Medicine & Child Neurology, 28(6), 757-761.
- Jiang, C., de Armendi, J. T., & Smith, B. A. (2016). The Immediate Effect of Positioning Devices on Infant Leg Movement Characteristics. Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association, 28(3), 304.
- Lenke, M. C. (2003). Motor Outcomes in Premature Infants. Newborn and Infant Nursing Reviews, 3(3).
- Littlefield, T. R., Kelly, K. M., Reiff, J. L., & Pomatto, J. K. (2003). Car seats, infant carriers, and swings: their role in deformational plagiocephaly. JPO: Journal of Prosthetics and Orthotics, 15(3), 102-106.

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 with a link to said image and it will be promptly removed.

Saturday, January 20, 2018

Massage - How it Benefits the Child and Caregiver

As the new year kicks off, one of my new year's goals is to decrease my stress level, and what better way to stay relaxed with a nice massage? If you have never received a massage before, I highly recommend it. It has so many benefits, including improving circulation, decreasing muscle tension, and reducing stress hormones. But have you ever thought about how it could benefit infants as well?! Infants also experience stress; whether it is a preterm baby who stays in the hospital for weeks after their birth, to older babies who have difficulty self-regulating, research has shown that massage can be beneficial not just for the infant, but for the caregiver as well! I took an online course about infant massage by Catherine McDowell, OTR/L, LMBT, E-RYT200/RYT500, who has been an occupational therapist for over 20 years and is also a licensed massage and bodywork therapist, and this blog post summarizes some of the key takeaway points from her lecture.

Some of the many benefits of massage for infants include relieving gas and colic, relieving constipation and improving elimination, and improving discomfort from teething and growing pains. It has also been found that the relaxation response from infant massage helps to improve sleep patterns, improve their ability to self-soothe and regulate their behavioral states, and reduces stress hormones. Research has shown that babies who are held, massaged, carried, and rocked grow up to have less aggression and violent behaviors as adults.

Infant massage has been found to benefit the caregiver as well. The eye contact, soothing touch, and calm voice are all essential for intimate parent-infant bonding and attachment. Incorporating this into the daily routine helps parents and caregivers feel more confident in caring for their child, provides quality one-on-one time with the baby, and teaches them how to read their infants' cues and recognize their awareness states. Mothers with postpartum depression have shown improvement in their mood and teenaged mothers demonstrate improved bonding behaviors with their infants after starting infant massage. 

While anyone can give a massage, the first choice to massage the baby are the parents, grandparents, or guardians. Other people who care for the child outside the home, such as nurses and therapists who work in neonatal intensive care units and work with people with disabilities, are important as well.

The setting of the space prior to giving the massage is crucial to providing a relaxing environment for both the baby and caregiver. The best time to massage your baby is shortly before bed, when they are in this "quiet alert stage." Make sure the room is warm and comfortable and that the lighting is not overwhelming. While singing and talking are extremely encouraged, keep your voice soft and calm, avoiding any loud, sudden noises. If you are giving the massage, make sure you have all your supplies and equipment in the vicinity prior to beginning the massage so that you do not need to interrupt the session. Make sure you and the baby are both in comfortable positions.

While daily infant massage provides benefits, some reasons to not perform this technique include: acute infections, recent surgery, fever, diarrhea, and less than 72 hours after immunizations. Consult with your pediatric physical therapist and your pediatrician before you begin to implement this routine.

McDowell, C. (2017). Benefits of Infant Massage for Both Child and Caregiver [Text/Transcript]. Retrieved from

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 with a link to said image and it will be promptly removed.

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.

- 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 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'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.

(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 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 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 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!


#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 with a link to said image and it will be promptly removed.


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.

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 with a link to said image and it will be promptly removed.