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.

Wednesday, November 2, 2016

Physical Therapy and Autism - Why PT is Beneficial!

When a kiddo is diagnosed with Autism Spectrum Disorder (ASD), the services most used for these kiddos include Speech, Occupational Therapy (OT), Applied Behavior Analysis (ABA), and Psych/Special Education(12). Many people don't realize that Physical Therapy is available for these kiddos as well!

Some clinical findings that you may see with kiddos diagnosed with ASD include low promixal muscle tone (especially in their core region), delayed postural reflexes, poor integration of reflexes, difficulty crossing midline, difficulty with visual tracking, reliance on peripheral vision, and difficulty with playground tasks such a catching and kicking a ball(4). Many of these kiddos may have some form of dyspraxia, which is a developmental coordination disorder, and may have poor motor planning - their movement execution is intact, but their movement preparation may be atypical. Kiddos diagnosed with ASD have a lack of anticipation, which can be related to motivation and/or attention(7). They may have difficulty with imitating movements, as they may difficulty perceiving biological motion and their visual attention has less attention to salient aspects of human interaction(9).

So where does PT come in? PT can help your kiddo improve their balance in order to access their environment more safely and independently. Studies show that kiddos diagnosed with ASD have abnormal proprioception, rely mostly on their visual system to maintain their balance, and have difficulty integrating their visual, vestibular, and somatosensory input for balance(5). Physical therapists are trained to help improve balance through a wide variety of static and dynamic tasks.

Gait may also be affected in kiddos diagnosed with ASD. One study found that gait in children with autism was consistent with cerebellar ataxia - they had difficulty walking on a line, had variable stride lengths and gait speeds, and postural abnormalities and asymmetries(8). These kiddos also have difficulty making improvements with external cues such as visual markers. Once they are in action, they have difficult using environmental cues to modify their movement. Physical therapists are experts at gait! We can help your kiddo learn how to walk more safely and effectively to prevent future injury and allow them to access their environment more safely and independently.

Kiddos diagnosed with ASD may also be at risk for becoming overweight/obese and have decreased fitness. Restrictive food preferences and gastrointestinal issues play a big role in overall fitness of kiddos diagnosed with ASD. Their decreased preference for group activities make it challenging for kiddos to participate in physical education class and extracurricular activities(3,6,10,11). Physical therapy can help your child boost their cardiovascular and muscular endurance through fun games and activities to help them stay active and decrease their risk of obesity!

Here are some learning strategies for kiddos diagnosed with ASD(1,2):
  • Focus on specific items in memory tasks rather than relational processing or seeing the whole task. This also relates to movement! For example, instead of focusing on diving into a pool, separate the task into different parts and focus on each part of the sequence of the dive.
  • Use one or two dimension visual aides to help teach a child a task. Because they have difficulty perceiving human motion, having a cartoon picture of someone performing the task or a doll may help them to understand better.
  • If they are also receiving OT and Speech, ask their OT and their SLP how they communicate with the kiddo and what have been the best ways for them to have success. Kiddos diagnosed with ASD do well with structure, so by tailoring your treatment session in a way similar to how their other therapists do their sessions will be beneficial for the kiddo to have success.
References
1. Bowler, D. M., Limoges, E., & Mottron, L. (2009). Different verbal learning strategies in autism spectrum disorder: Evidence from the Rey auditory verbal learning test. Journal of Autism and Developmental Disorders, 39(6), 910-915.
2. Brown, J., Aczel, B., Jiménez, L., Kaufman, S. B., & Grant, K. P. (2010). Intact implicit learning in autism spectrum conditions. The quarterly journal of experimental psychology, 63(9), 1789-1812.
3. Lang, R., Koegel, L. K., Ashbaugh, K., Regester, A., Ence, W., & Smith, W. (2010). Physical exercise and individuals with autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 4(4), 565-576.
4. Ming, X., Brimacombe, M., & Wagner, G. C. (2007). Prevalence of motor impairment in autism spectrum disorders. Brain and Development, 29(9), 565-570.
5. Molloy, C. A., Dietrich, K. N., & Bhattacharya, A. (2003). Postural stability in children with autism spectrum disorder. Journal of autism and developmental disorders, 33(6), 643-652.
6. Rimmer, J. H., Yamaki, K., Lowry, B. M., Wang, E., & Vogel, L. C. (2010). Obesity and obesity‐related secondary conditions in adolescents with intellectual/developmental disabilities. Journal of Intellectual Disability Research, 54(9), 787-794.
7. Rinehart, N. J., Bradshaw, J. L., Brereton, A. V., & Tonge, B. J. (2001). Movement preparation in high-functioning autism and Asperger disorder: a serial choice reaction time task involving motor reprogramming. Journal of autism and developmental disorders, 31(1), 79-88.
8. Rinehart, N. J., Tonge, B. J., Iansek, R., McGinley, J., Brereton, A. V., Enticott, P. G., & Bradshaw, J. L. (2006). Gait function in newly diagnosed children with autism: cerebellar and basal ganglia related motor disorder.Developmental Medicine & Child Neurology, 48(10), 819-824.
9. Rogers, S. J., & Vismara, L. A. (2008). Evidence-based comprehensive treatments for early autism. Journal of Clinical Child & Adolescent Psychology, 37(1), 8-38.
10. Sowa, M., & Meulenbroek, R. (2012). Effects of physical exercise on autism spectrum disorders: a meta-analysis. Research in Autism Spectrum Disorders, 6(1), 46-57.
11. Srinivasan, S. M., Pescatello, L. S., & Bhat, A. N. (2014). Current perspectives on physical activity and exercise recommendations for children and adolescents with autism spectrum disorders. Physical therapy.
12. Wise, M. D., Little, A. A., Holliman, J. B., Wise, P. H., & Wang, C. J. (2010). Can state early intervention programs meet the increased demand of children suspected of having autism spectrum disorders?. Journal of Developmental & Behavioral Pediatrics, 31(6), 469-476.

13. Ronan, S. (2015). An Evidence Based Approach to Gross Motor Dysfunction in Children with Autism [Powerpoint slides]. Retrieved from  Columbia University Program in Physical Therapy.

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.