Some Thoughts on Perplexus

   

We have a few of the Perplexus models here because I think they are really cool. For those of you who have never seen them they are a clear globe with a complex track inside that is broken up by colors and you need to keep a small ball on the track from the start to the end.  It is a great way to work on motor planning, visual motor skills, and bilateral coordination.

I recently decided to try the ‘rookie’ with my kiddo who has spastic quadriplegia CP.  I wasn’t sure how it would go based on his physical challenges but I knew intellectually he was bright enough to know what to do.  It was really interesting to watch him try to work it out.  First I demonstrated it to him and he talked me through which way to turn the globe so that the ball stays on the track.  He was able to verbally instruct me as well as point to the direction of movement that I needed to move the globe.  Clearly he understood the concept of it.

Next I gave it to him.  He concentrated so hard on it but had a really hard time moving the globe within his hands.  It was easier for him to keep his hands stable on the globe and try to twist it.  When he did this the ball frequently fell off the track.  I began working with him on how to turn the globe within his hands.  I used some hand over hand and step by step verbal cues and he began to get the hang of it.  He needed to use a lot of extra stabilization such as with his chest and his chin while he attempted to move his hands without the globe moving with them.  He also did a great job of maintaining an upright posture while doing this activity.  He has a tendency to slouch when sitting in a chair and performing activities with his hands so it was great to see that this game allowed him to maintain his postural stability much better than normal.

I would say with a kiddo like this the motor planning required for the bilateral coordination of his hands and then integrating the visual is what it really works on.  Whats great is that because it is broken up by color you can create goals such as get to the red track and then get to the purple track, so that they don’t get frustrated when the ball falls off the track.  When I did step in and help a bit I had him continue to direct how we should turn it so that he was able to continue his intellectual and visual problem solving.

How have you used the Perplexus?

Internal Rotation and Walking

Okay, I tried to get creative with the title and my creative juices just are not flowing today!

This post looks at internal rotation and walking (as if you couldn’t figure that).  We have several kiddos that we see that use excessive internal rotation when walking (toes pointing in) and many times parents ask how we can correct that.  What we have found for a lot of these kiddos is that while they do have internal rotation, it is not as excessive as it may appear when they are walking.  Many kids will use compensatory movements while walking for a variety of reasons.  Some of the things we have found that contribute to the appearance of excessive internal rotation are the use of circumduction (swinging the leg around causing an internal rotation like movement), pelvic instability (so because of weak hip abductors they can’t maintain a level pelvis when they take a step and the side of the pelvis that is taking the step will drop down causing the leg to look like it is going further into the center), and initiating swing from the pelvis (so instead of a straight plane step through they are swinging their leg through using the whole pelvis).

We have found that if we can provide stability at the pelvis, or even slow the kiddos down while walking some of these compensations will decrease.  When the compensations decrease, you will still have the internal rotation that is already present but you won’t have the illusion of more rotation because they will be using more deliberate actions.

We have also found that when kiddos get AFO’s or other orthotics it will also increase the appearance of internal rotation for some of the same reasons.  I’ve mentioned before that when you change one thing you will see changes in other areas.  So when a child gets a new foot brace, they may be trying to figure out how to use it and it can alter their swing phase of walking and bring out compensations.

I’m not sure how well you can see it in the video but in the first part the child moves fast and uses their body to lean into the movement and they have poor pelvic stability as well as increased circumduction/use of their pelvis to initiate swing phase.  When we changed the walker and gave them some hip stability, as well as used leg cuffs to not let the leg drop into the middle (that can happen when the pelvis drops) the appearance of internal rotation decreases.  You can see more deliberate stepping and they aren’t able to use their momentum to keep them moving.

Using a walker isn’t for all kids but for this particular child it was one way to decreased the excessive internal rotation that was happening.

We did not try to correct for his actual internal rotation because of his age and the fact that bony changes have occurred altering the alignment of his femur.  By trying to use strapping to make his toes point forward we would have put his hips at risk.

What have you used to help kiddos that walk with this similar pattern?

Postural Control – How the Systems Work Together

Postural control is a term used to describe the way our central nervous system regulates sensory information from other systems in order to produce adequate motor output or muscle activity to maintain a controlled, upright posture. The visual, vestibular, and somatosensory systems are the main sensory systems involved in postural control.

The visual system contributes to postural control by delivering information from the retina to different areas in the brain that allow for object identification and movement control.  Therefore, if your child has a visual impairment, it may be affecting their ability to control their posture and balance especially during movement.

The vestibular system, which consists of organs located in the inner ear, contributes by interpreting changes in movement, direction and velocity or speed of movements. This information is sent to the brain stem, which then creates a response that allows your postural muscles to activate and increases your body awareness.  The vestibular system can be affected in children with various syndromes and disabilities.

The somatosensory system contributes by relaying information about body position to the brain, allowing it to activate the appropriate motor response or movement.  Specific receptors or gauges called proprioceptors are located in our muscles, tendons, and joints.  These are the receptors that are able to tell our brain whether our knee is bent or straight, whether we are bearing weight or not, and which muscles are contracting and which are relaxing at any moment. Inadequate somatosensation will affect postural control as well.

So you can see that all three of these systems play an important role in maintaining postural control and balance.  To ensure proper postural control, the sensory information from these three systems must be regulated by the central nervous system in order to produce an appropriate motor response.  So what does proper postural control look like? This is when an individual is able to engage in various static and dynamic activities, such as sitting, standing, kneeling, quadruped, crawling, walking, and running with the ability to contract the appropriate muscles required for a controlled midline posture, as well as the ability to make small adjustments in response to changes in position and movement, without the use of compensatory motions. If even one of the mentioned systems is not working the way it is supposed to it can affect postural control and balance.  However, when one system is affected the other two can be trained to compensate.  If more than one system is affected in combination with central nervous system involvement postural control will be more greatly affected.  Talk with your therapist for ways to assist your child achieve improved postural control.

Using the Ball vs the Platform Swing for Balance Reactions

  

As a therapist, we use the therapy ball a lot with our kids.  It helps them to work on balance reactions and postural control as well as provides vestibular input in a variety of directions.  The kids love it because usually we sing to them and bounce them and they may even forget they are working.  There are a few things to consider when using the ball though.  Generally you are holding onto the child in some way so they are being provided stability (most likely at the pelvis) which allows them to only concentrate on activating their core without having to figure out how to counterbalance at the pelvis.  In addition, usually kids are sitting with their feet hanging down in front of them so they are able to pull in their leg muscles to assist with activating their trunk muscles by using the overflow.  If they over recruit their muscles, they can generally push against your hands to give themselves extra support.  Finally (although I am sure there a quite a few more points that I didn’t bring up), if you are holding them at their pelvis or even their trunk, I can almost guarantee that you are helping them correct their posture in some way, shape or form.

Another alternative to use in conjunction or to switch it up is to utilize a platform swing.  You can have the child sit in ring sitting, tailor sitting, side sitting, etc in front of you and then you can move the swing forward, backwards, sideways or even diagonal (similar to the directions you can move the ball) and see how the child reacts.  This method is great because it can let the child practice sitting ‘independently’ (although with you close by) so they can practice using their pelvis to counterbalance their trunk reactions.  For example, if the swing moves to the right, the child needs to stop the movement towards the right by pushing their left hip down into the surface and use their trunk muscles to shift them back to midline.  In the beginning, especially with the side to side motions, kids have a hard time preparing their body for the movement and need help to not topple over.  I usually start with slow, small movements until they begin to get the hang of it and then I will increase the speed or the size of the movement.  By having their legs crossed in front of them they also have to work harder to isolate their trunk extensors and other trunk muscles.  If you have a kiddo with higher tone, they will attempt to push their legs into extension while trying to stabilize.

Now I know not everyone has access to a platform swing so what other tools or tricks have you used to work on balance reactions on a dynamic surface, without giving the kiddo stabilization?

Backpack Safety for Back to School

image retrieved from: tucsonweekly.com

With school starting again, most kids will be asking for new backpacks to help carry their supplies to and from school.  Make sure you are aware of how to help them prevent injuries by understanding backpack safety.

Every year the American Occupational Therapy Association (AOTA) has a National School Backpack Awareness Day.  This years is September 19, 2012.  They have also published several handouts on proper backpack use and safety tips as well as several videos for both kids and adults to watch.

It’s recommended that kids don’t carry more than 10%-15% of their body weight in a backpack in order to prevent back aches and injuries.  This means if your child is 50 pounds they shouldn’t be carrying a backpack that weighs more than 5-7 pounds.  With the increase in homework this may prove challenging.   There are some solutions out there that are presented in this ABC’s of backpack use.  Some of the practical ones suggest using backpacks with wheels, organize the backpack so that the heaviest items are the ones that are closest to the back, bigger isn’t always better (its harder to overstuff a smaller backpack).

Because of the high number of injuries from backpack use its recommended that you talk to your children about telling you if their back hurts, they have numbness or tingling.  Also it helps for you to note if your child’s posture changes when they are wearing their backpack.  Do they arch their back more or slump more?  All of these are signs that the backpack is too heavy or not fitting correctly.

What backpacks have you found fit well and are safe for your kids?

Some Thoughts on the Bumbo Recall

image retrieved from: nwcn.com

It recently made the news that the Bumbo chair has been recalled because of the potential for skull damage to infants.  The recall will provide safety straps to the chair to potentially prevent injury.  Since this recall has been announced several pediatric therapists have taken the time to put their thoughts down.  One of these therapists is an old classmate of mine from PT school and I thought she had some great points in her blog post ‘In Defense of the Bumbo‘.  Another great post was by Kendra Ped PT ‘More Trouble for the Bumbo‘ where she discusses her thoughts on the Bumbo chair as well as reminders about proper use for all infant equipment. We have also posted about the use of infant equipment in the past as well.  Although I did not in the post mention the therapeutic benefits of using the Bumbo chair.  Therapy Fun Zone has also posted on the Bumbo seat as a product review and how they have used it therapeutically.

I think that all of these blogs make great points.  The other thing that I would add is that many people tend to use the Bumbo too early with their kids.  If your child isn’t able to hold their head or back up on their own, or even with you holding them at the hips, then they should not be left in the Bumbo chair.  If you need to leave them in a seat for extended time there are other products that will provide them with the support that they need.  If your child is having trouble with head and trunk control and you are using it to help them work on this skill, you wouldn’t be leaving them in it unsupervised for extended periods of time.  It would be during a supervised session of you engaging them so they are actively working to lift their head and trunk and thereby learn to become more independent with sitting skills.

Hopefully these posts will help you to figure out great ways to use the Bumbo chair appropriately and effectively for your child.

Postural Control

I talked a little bit about anticipatory and reactionary balance in one of my last posts.  In addition to balance and the ability for a kiddo to stay upright, there is also postural control.  Postural control looks at how we can maintain our posture while going through the activities of our day.  They are all tied together but I thought I would try to explain postural control a bit.  Then you can put the two pieces together and hopefully have a better understanding of how it all works together.

For some kids it takes a lot of practice to turn their muscles on to hold an upright posture.  However, even if they are able to attain an upright posture can they maintain that posture while walking, or writing, or raising their hand, or eating?  The goal of working on a child’s posture (or even ours) is that they are able to keep their muscles activated while doing the above mentioned activities as well as any other activities that they do in their life.

As I’m writing I realize this is harder than I thought to put down logically into words.  Let me try another way.  As I’m getting older I notice that my back is hurting more often.  This usually means that I was doing something and wasn’t able to maintain my core muscles activated as much as I should have so my back was moving more than it should have.  Basically I wasn’t able to maintain postural control because the task was more demanding than my muscles could maintain.

So, when working with kiddos some may be able to maintain an upright posture with everything they do while some may only be able to sit for 10 seconds with external help, such as someone stabilizing them at their hips.  Some kids fall somewhere in between. The more demanding the task, whether physically or mentally, the harder it is to maintain postural control.  For instance, in the example I gave involving my back, the demands of the task were too physical for me to maintain my postural control.  An example of being too mentally demanding would be if a kiddo needs to concentrate on their posture, they have to think about what they are doing, if you start talking to them or asking them questions, they aren’t able to concentrate on both activities at once so they lose postural control.

It also becomes easier to lose postural control with increased fatigue.  So as I become more tired, or a kiddo becomes more tired, it is harder to concentrate on posture.

I hope this made things a little clearer…

 

Anticipatory or Reactionary Balance

For the sake of this post I am going to combine the idea of balance and postural control.  They are not exactly the same thing but they are similar in terms of what I am going to talk about.  Most people just think that balance is what keeps us upright.  While yes that is true its amazing how complex it can be. I am going to attempt to keep it simple (hopefully I succeed).

If you are walking down a hall and someone runs by from behind and bumps into you and you don’t lose your balance, you are using reactionary control.  You had no idea it was coming and yet you were able to react to what was happening to you and stay upright.  Maybe you needed to use your hands (protective extension) or take a few steps but you were able to pull together strategies to stay upright and not fall.  Another example of reactionary balance is if you are walking and the ground changes and you weren’t paying attention such as a slight change in height or a change in surface stability.  Your body has to react to stay upright.  This idea applies to whether you are sitting, standing, walking, running, etc. With reactionary the kiddo’s body needs to recognize that its balance has been disturbed and then send out the message to get the correct adjustments being made in just the right amount of time, in just the right sequence and with just the right amount of force (I feel like I’m quoting Goldilocks and the 3 Bears!).

With anticipatory it is when you are about to do something and your body makes the adjustments it needs to in order to stay upright.  For example, whenever I go to the Cheesecake factory they bring out those large water glasses and I go to pick it up, expecting it to be glass and I almost give myself a bath because it is plastic and much lighter than my body had prepared for.  The next time I go to pick it up I have made the necessary adjustments and can pick it up without dousing myself.  Another example is if a kiddo is just learning to crawl and they are figuring out how to move one arm and then the next and then the legs as well, all without falling flat on their face, they are learning the adjustments their body needs to make so that they can anticipate lifting their arm without losing their balance.  Same thing applies to kicking or throwing a ball or reaching for an object or almost anything we do on a daily basis.  With anticipatory the kiddo’s body needs to recognize that something is going to happen that will disturb its balance and make the adjustments before it happens.

What’s interesting is that often anticipatory starts as reactionary (in my experience).  Think about it, lets look at the kiddo I mentioned above who is learning to crawl.  The first time they lift their arm they can’t hold their balance and they fall.  When they try it again they still don’t know what their body needs to do but they know they might fall so they are a little more prepared.  They lift their arm and start to feel themselves falling so they react to this loss of balance and manage to keep their balance.  The next time (ok, I’m speeding up the sequence, it probably takes lots of attempts for each adjustment) they now know they were able to stay up so their body starts to anticipate what will happen when they lift their arm and they are able to lift it and move it to a different spot all while maintaining their balance.  They of course start the whole process over again with each arm or leg they move and then even more so when they try to move the arm and leg together , or go onto a slippery floor instead of carpet.

Hopefully that explanation made sense and you can see how it can apply to almost every movement or task we do throughout our day.

In one of my upcoming posts I’ll talk about some ways to work on balance (anticipatory and reactionary), in the meantime I challenge you to pay attention to when you are using each of the types throughout your day!

 

Ideas for Helping Kids Develop Better Posture

Posture is always an interesting topic.  As adults we are often trying to improve our posture because we have started discovering that poor posture can cause other problems like pain.  These are things we don’t think of when we are younger and don’t always think about for our kids.  Posture is something that can and should be worked on from when kids are little so that they can hopefully avoid long term problems as they get older.  I have to thank one of our readers for coming up with this idea!

Here are some tips and ideas for exercises/playing that can also work on posture:

• Make sure kids hamstrings stay flexible.  Its a lot easier to keep them flexible than to stretch them later.  When hamstrings are tight it can tip our pelvis backwards so that it flattens our low back spine.  To help with keeping hamstrings flexible have kids avoid w-sitting and long periods of kneeling as these will both shorten the hamstrings.  They should sit in a variety of positions such as ‘criss cross’ or with their legs straight out in front of them.  Here are some different sitting positions.
• Core strength is really important.  Some of my favorite ways to improve core strength for kids other than having them do sit ups are:

1. Lots and lots of climbing.  Since its getting nicer out this should be easier because parks are lots of fun.  The more unstable the climbing surface the more they will have to work their stabilizers and abdominals.  I love climbing nets or climbing domes.  Even ladders work well for this.
2. Animal walks are a lot of fun and really challenge the core.  Some of our favorites are bear walking (hands and feet) or crab walking or dog/cat walking (straight crawling).  You can have animal parades or animal races.  You can change the terrain by going over uneven surfaces such as cushions or you can go up and down hills.  You can make animal obstacle courses where they have to be the animal and go around cones, over obstacles and through tunnels.
3. Use a therapy ball.  Have your kids sit on it and move it around in all directions with fast and slow motions.  Or have them bounce on it. Try to give as little stabilization as possible (try for just the legs) and make sure they aren’t using their hands to hold on.  If you can get them to engage their hands in play such as clapping or touching their head or reaching to the sky it automatically encourages more upright posture.  I will also have kids reach for items such as bean bags and then throw them for a target while sitting on the ball.

• Try sitting on an unstable surface.  There are wedges or core discs that are out there that can provide the ability to wiggle while sitting and allow kids to keep their core active and engaged.  You need to try it out though because sometimes it can be too challenging and they will just sink into a slumped posture.  Also if you can make a sitting surface a little higher than normal so their feet still hit the ground it can encourage an upright posture more than sitting at 90/90.  Or if you have a therapy ball that they can sit on with their feet on the ground while watching tv or doing other things it really works to keep the core active.  You have to make sure that they are safe while doing this though.
• Swinging at the park especially when they are self propelling naturally engages the postural muscles such as the scapular retractors and the abs. In addition they get some great vestibular input.
• Bike riding is really fun and great for core strength and endurance.  If you really want to get the core working ride up slight inclines and hills, they will have to use their arms and abs to generate power from their legs.
• Reaching in sitting will also encourage upright posture.  Have them sit in a variety of positions or on a variety of surfaces and play games where you make them reach up and in front or to the side.  Watch their posture to make sure they are engaging their core muscles.

I probably have a ton of other ideas but this is a start.  What are some of your favorite ‘exercises’ for encouraging improved posture with kids?

Spots – Multiple Fun Uses!

     

I love when I find an unexpected treasure (and in the $ bin no less)!  This morning I stopped at our local Rite-Aid to stock up on soda (not healthy I know but sometimes that’s what it takes to keep up with the kids) to feed our addictions at work and I was meandering through the store and I found these frog and ladybug circle pads that are made of foam and look just like the spots that we used to buy from Ikea (which they no longer carry).  I love the fact that they have animals on them because the kids love using our bean bags that are shaped like turtles and frogs and bugs, so having spots with animals gives them one more cue as to where we want them to be.  What do we use spots for you may wonder?  Well the list is endless but here are a few of our top things:

• We make paths with our spots for having kids jump along the path, hop on one foot along the path, and skip over spots while jumping or hopping.  It creates a great visual cue when you are able to tell them a color or animal to jump to next.  Its great for beginning jumpers as well as for jumpers that you are working on getting consecutive jumps out of.
• They provide a great visual for a kid to stand on.  I use them all the time when I want the kiddo to be standing ‘still’.  For instance when playing catch or bean bag toss or basketball, they often want to move closer and I can ask them if they are on their circle and they generally immediately go back to it.  We use them in group for circle games so the kids have an idea of where their space is.
• They are great targets for the stomp rocket or throwing things.  You can have the kids work on aiming for the spot, especially with bean bags or flat discs since they don’t roll.
• We use them on the stairs to provide a visual cue for which foot to place down next.  This is great for working on alternating feet as well as giving a clear visual target for where to place your foot.
• Also when they are in a path it can be used to work on narrowing a kiddo’s base of support by having them stay on the circles or for increasing their step length by having them place one foot on each circle.
• You can have kids balance them on their head for posture and body awareness while standing or walking.
• We use them in obstacle courses so that at each spot they have a new task/skill that starts such as standing on one foot, lifting the heavy ball, doing jumping jacks, etc.
• They are also great visual cues for early jumping jacks skills by placing them in a sequence of 1-2-1-2 to begin working on jumping open, then jumping together.  It is also great for early hopscotch of one foot, two feet.

What are some of the things you use spots for?