Growth Spurts

When working with kids, growth spurts are always something we have to take into account.  I can remember as a child feeling like I had these arms and legs that weren’t connected to me making me even clumsier than I already was.  On top of that I think I was hungry all the time too.  Almost all kids go through growth spurts at various times during their developmental years so I just wanted to take a moment to point out some things to consider during these times.

For all kids, when they grow rapidly their bones change lengths, their muscles have to adjust and as a result their ability to sense where they are in space has to alter.  It doesn’t happen overnight (hence me feeling like my arms and legs weren’t attached) and during the time when their bodies are adjusting to these new proportions they may be a little on the clumsy side.  Just think for a second of your house and your daily routine.  I bet you know exactly where everything is and can almost go through your morning routine in your sleep.  Now imagine that someone came in during the night and moved everything around.  I bet it would throw you off for a few days while you adapted to the new layout.  That’s how kids have to adapt to their ‘new’ body.

When a child has low muscle tone or high muscle tone there are other things to consider.  For a child with low muscle tone, they are working hard to maintain strength and stability.  Their muscles get good at working at a certain length and they begin to progress their skills.  Now they grow suddenly and their muscles are longer and all of a sudden they aren’t as efficient and their endurance is decreased.  They will show some weakness and have a harder time with postural stability and overall functional skills.  This is their period of adaptation to their new size.  It just may take them a little longer, and they may look like they have regressed.  You may have to give them a little more help or a little more time for a short period, but the good news is, they get back to their previous abilities much faster than the first time around when they were just learning the skill.  That’s because their body already knows what to do, they just have to figure it out at this new size.

Hopefully this helps explain some of what you may see as your child is growing and they appear to change over night, don’t worry, its not permanent!

Low Tone and Growth Spurts

We frequently have children of all ages in the clinic who have been diagnosed with low muscle tone (hypotonia).  This can often be confusing for parents and difficult to explain to others so we wrote ‘What Does Low Tone Mean?’ to help with that explanation.

Recently, my coworkers and I were talking about a few babies/children who we were seeing who have low tone and how we could see the progress they were making but it was often hard for the parents to not only see but to understand why it might possibly be taking ‘so long’ or longer than other children.

As a sidebar, I love having other therapists around to discuss the kids we are lucky enough to work with.  By discussing the kids, we are able to help pull the pieces of information and ideas we have in our head and synthesize them into something that makes sense and we can explain to others! What came out of our discussion is:

When a child has low tone, we have already acknowledged that they have to work harder to engage their muscles and keep them turned on to complete activities.  As the child uses their muscles they are helping to get them stronger so that they can generate more force and maintain that force generation for longer periods of time (endurance).  For instance, when a baby is working on tummy time they have to turn their muscles on to lift their head up off the support surface – to do that they need to be able to generate enough force so that their muscles can turn on and lift the head.  Once they have their head lifted up, they need to be able to keep that force turned on long enough so that they can look around.  With practice it gets easier to lift their head and they can do it for longer periods of time.

That is until they grow.  A child in their first year of life is in a constant growth spurt for the most part.  Not only is their body changing, but they are constantly learning new skills for their development.

If you think back to when you were a child in elementary or middle school and you hit a growth spurt (or to other children you have seen if you can’t remember yours!), it was as if you woke up with a whole new body.  You were probably a little bit clumsy (in my case a lot clumsy since I was already clumsy to begin with) and your movements were not very coordinated.  I often visualize a baby lamb or horse or giraffe taking their first steps when I think of young kids going through growth spurts.

Now, put that same awareness on a little baby who is changing every day.  Especially if that baby has low muscle tone.  Our muscles learn to work in a certain way and they get really efficient at it.  If you change their length or change the weight that they have to move, all of a sudden they are a little less efficient.  For kids with low tone, they are playing a constant game of catch up.  They are working hard each day to get stronger and become efficient but then someone goes and changes the parameters of the game on them.  Now they have to learn how to work at a new length with a new weight, and very often a new activity.

And, each time they grow or are faced with a new developmental task, they need to find their stability again before they can work on their mobility.  For instance, its very hard to reach for a toy in sitting, if they are having trouble generating the strength to hold themselves in sitting, or its hard to crawl if they can’t hold themselves in a hands and knees position.  So, with each growth spurt, they will need to relearn how to find stability before they can go back to working on their mobility.

Hopefully I helped to explain things a little and didn’t just make it more confusing!

Should I Be Concerned: Gross Motor Edition (up to 15 months)

A lot of times my friends and relatives ask me questions about their child’s gross motor development (especially if they are first time parents and have nothing to compare it to) and if they should be concerned so I decided to writie up a list of items that may be an area of concern for kiddos at 3 month intervals.  This list doesn’t necessarily mean there is a problem but it doesn’t hurt to take a look and see if some of the things you are noticing continue to be a challenge.  Many times I find that if there are some slight challenges with gross motor, the earlier the parents and the kiddo get tips on how to help develop the skills, the quicker the child catches up.  I tried to take a slightly different approach than the typical look at gross motor milestones because there is such a range in milestone acquisition that often parents aren’t sure if their child is behind or not.

General Concerns:

• Very stiff or very floppy
• Torticollis/plagiocephaly (flat spot on the head)
• Prefers standing all the time
• Lack of opportunity for independent motor exploration (time spent out of equipment/carriers/bouncies/etc)
• Profound or significant birth/medical history
• Generally still (not moving) when awake
• Persistent ATNR

Three Months:

• Difficulty lifting head on belly or on back
• Stiff legs with little to no movement on belly or on back
• Pushes back with head
• Tends to keep hands fisted with little to no arm movement on back
• Challenges with bringing hands and/or head to midline on back

Six Months:

• Items listed previously
• Back is rounded or slumped
• Unable to lift head up in sitting, supported or unsupported
• Poor head control
• Arches back and stiffens legs
• Holds arms back and up (i.e. high guard)
• Has stiff legs
• Keeps legs in a frog leg position on belly or on back
• Doesn’t like to be on their stomach
• Thrusts into extension for movement (such as rolling or when sitting)
• Not able to roll
• Doesn’t bring feet to mouth or feet to hands on back
• Doesn’t weight bear on arms when on belly
• Doesn’t tolerate or like sitting
• Unable to sit supported
• Doesn’t kick legs
• Unable to lie on side

Nine Months:

• Items listed previously
• Uses one hand predominantly
• Poor use of arms in sitting
• Difficulty crawling
• Only uses one side of the body to move
• Inability to straighten back
• Can’t/won’t take weight through legs
• Prefers lying on back rather than on belly or exploring
• Doesn’t weight bear through upper extremities
• Uses bunny hopping or butt scooting as only means of mobility
• Uses w-sitting as primary method of sitting or a wide based ring sitting
• Inability to weight shift through legs or arms
• Inability to move legs separately from each other
• Difficulty getting onto hands and knees

Twelve Months:

• Items listed previously
• Difficulty getting to stand because of stiff legs and pointed toes
• Relies on arms rather than legs to get into standing
• Sits with weight to one side
• Strongly flexed or stiffly extended arms
• Needs hands to maintain sitting
• No desire or ability to climb onto objects
• Avoids standing
• Trouble transitioning between positions (i.e. sitting to hands and knees, lying down to sitting)
• Difficulty with cruising
• Not attempting to walk with support

Fifteen Months:

• Items listed previously
• Unable to take steps independently
• Trouble maintaining standing balance
• Walks on toes

This is just a guideline for some areas that may be cause for concern and for peace of mind may be worth having a pediatric physical therapist take a look at your kiddo.
References:

Bly, L. (1994). Motor Skills Acquisition in the First Year.  San Antonio, TX: Therapy Skill Builders.

http://pathways.org/awareness/parents/new-parents/monthly-milestones/

What Does Low Tone Mean?

Muscle tone is the resting state of your muscles.  When a child has low muscle tone it means that they need to put a lot more energy into getting their muscles to turn on to do what they want them to do.  I often try to explain this to parents by describing that feeling when you finally get to sink into the couch or your favorite arm chair and relax and then someone calls you from the other room and you have to rev up the energy to get up.  Think about having to do that every time you move because that’s what it can be like for kiddos who have low tone.

Generally kiddos with low tone seem to be squishable because they melt right into you when you hug or hold them.  This is great for cuddling but if you are carrying a baby or kiddo around that is melting into you, it means they aren’t able to help support themselves in your arms so it can seem as if you are carrying a heavy weight around.  As their muscles get stronger they get better at activating them so that if you are carrying them, they can hold their own trunk up without having to lean on you.  Its amazing how much lighter this can make them feel!  (Another way to get the idea is if you are holding a kiddo by their hands to help them stand and they just decide to have spaghetti legs and you weren’t expecting it).

When I talk about strength being a challenge for kids with low tone I am talking about not just their ability to generate enough force to move their arm or their leg, but also their endurance and their ability to switch their muscles on and off.  These components all work together to produce movement.

I know that I talk about core strength a lot but for these kiddos its really important.  Just think if your trunk (core) was as stable as a slinky.  Do you think it would be easy to move your arms and legs, to do fine motor activities, to run and jump or even walk, to keep an upright posture in school to help with learning?  It would be challenging to do all of these things and so many more. That’s why when I work with kids with low tone I am often doing activities that will challenge the whole body but also focus on the core.  I also work to increase either how long they can do an activity (such as sitting on a ball for trunk control) or how many times they can do something (such as bridging) because this will help to increase the endurance of their muscles so they can stay working as long as they want them to.

Since it is harder to move and to activate their muscles, a lot of times they may need more practice, help and support, not to mention motivation to get moving! When they are little I do lots of tummy time to develop their butt muscles, anti-gravity trunk extensors, their head and neck muscles and their shoulder muscles.  The more interesting you can make the activity the longer you can get them to want to play in this position.  I do other activities as well, such as pull to sit to work on abs and head control (I make them work both going up and going down).  Going down is often easier (until you get close to the ground) because their muscles are already turned on so they just have to keep them on so they don’t ‘crash’ unlike going up where they have to turn their muscles on and its really hard when you are flat on the ground because you are fully working against gravity. I could go on all day and I might have to do another post just on activities!

Since these kiddos have to put out so much more energy to do things than a person with regular muscle tone, and the fact that we are constantly asking them to do more, don’t be surprised if they get tired easily.  For instance, it may not seem like it is that hard to sit in a chair to do work but if you think about all the energy they have to expend to keep their body up nice and straight its not surprising that they are tired.  When they are little they may need to nap more often, especially if they are doing therapy.  If you are in a mommy and me or a gymboree class you may notice that your kiddo needs to take breaks a little more frequently than the other kiddos.  This is normal for them.  However, you also want to remember the goal of working on their endurance so it doesn’t hurt to challenge them.  Just like when I am training for a race, 3 miles may be in my comfort zone but to get to the marathon I will have to challenge myself to run a little bit further than my comfort zone allows each day.

TheraTogs or the Spio suit or even hip helpers are tools that can be helpful for kids with low tone to give them a little extra support in the core so that they can practice the skills they need to practice.  I also use a lot of tickling to remind a muscle to turn on and stay on.  Sometimes using a slightly unstable surface like a sitting disc or a therapy ball can also be a reminder to keep muscles on.  Since it is unstable its a lot harder to sink into the support like they would be able to in a nice firm chair.  Also using wedges (although I wish I could find these filled with sand in addition to the air filled ones) in a chair (tilted forward) can help to activate a child’s core for improved sitting as well.  What are other tools that have helped either kids you have worked with or your own child – I’m sure I’m leaving out a ton of ones I’ve thought of or used but I always love to hear new ideas!

You can download an informational handout of this information here!

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Autism and Gross Motor Skills

In the most recent issue of Pediatric Physical Therapy there are three articles regarding autism/autism spectrum disorder and gross motor skills.  I was actually really excited to see this because I sometimes feel that gross motor skills get put on the lower end of the priority scale for kids who are diagnosed with autism, autism spectrum disorder, or PDD-NOS.  Now don’t get me wrong, I understand that there are only so many hours in a day and there are so many areas that you need to prioritize for your child’s development.  Gross motor is easy to overlook especially if they are walking and able to get around independently.

I just thought I would take a moment to highlight some of the benefits of working on gross motor skills with children who are diagnosed on the autistic spectrum.

• Strength and posture – Generally kids with this diagnosis have lower muscle tone.  This low muscle tone can cause them to fatigue quicker, have challenges with postural control, and make learning new tasks more demanding (which can make it harder).  Working on activities to develop core strength and overall muscle strength will help with these challenges which can aid them in paying attention in school because of improved posture, trying out new skills, playing longer with their peers during active play.  In addition, fine motor skills and speech skills can improve as a result of improved strength and muscular endurance as well as opportunities for active play.
• Coordination – Learning new skills can be challenging because of weakness and low muscle tone as mentioned above, however it can also be challenging if it is hard to organize all the pieces that make up a skill.  For example, jumping jacks involve jumping, arm movements, leg movements and timing/rhythm.  Just one of these components may be challenging so being able to practice breaking down the pieces of the task and then as they master the pieces putting them back together for the whole motion can help your child to achieve the skill in a more timely manner and with less frustration.
• Social skills – I have worked with several kiddos who are diagnosed as being on the autistic spectrum and concerns with families are often around their ability to interact with their peers and play.  Because learning new skills may be challenging that can make it harder to keep up with peers as they continually evolve their play and gross motor skills.  For example, jumping is a skill that kids love to do when they figure it out.  If your kiddo is having trouble jumping they may be missing out on valuable opportunities to relate to their peers in a play based way.  Same with bike riding or even being able to participate in PE or recess.
• Sensory – Depending on your child’s sensory needs, adding in gross motor play will allow your child the opportunity to get a variety of sensory experiences such as proprioceptive feedback to their joints (which can also help to keep low tone muscles ‘awake’), vestibular input to their inner ear from moving up, down and around, as well as tactile input from the various surfaces they may come in contact with during play.  Let’s Play and Get Messy! touches on some of the sensory aspects of play.

I am definitely not writing this to tell you to add one more thing onto your already busy and probably completely scheduled days, but just to help you look for opportunities to add gross motor practice into your day.  If your child is working with other professionals you can ask them to include some gross motor into their activities.  Or maybe find out from their teacher what their peers are doing on the playground or in PE so you can have ideas for active play in your household

Top 10 Blog Posts of 2011

I love Top 10 lists!  Here is this years list of Top 10 Blog Posts:

10.  Core Muscles:  Building a Solid Foundation

9.  No Kid Left Inside – Benefits of Outdoor Play

8.  Having a Ball With Core Muscle Strength

7.  Gross Motor Development vs. Fine Motor Development

6.  Standing Straight and Tall

5.  A Glossary of Sitting

4.  Let’s Play!

3.  What is Protective Extension?

2.  Why is W-Sitting a Four Letter Word?

And the most read blog post by a landslide:

1.  Torticollis:  What Is It?

Thanks for everyone who reads and I look forward to the next year!

W-Sitting Revisited

I have decided to post again regarding one of my more controversial topics: w-sitting. W-sitting is a very natural form of floor sitting just like tailor (crisscross cross applesauce) sitting, ring sitting, side sitting, long sitting, and kneeling. All of these positions can be assumed and transitioned out of. In fact I discussed the beauty of movement variability in the development of movement in my previous post.  I was re-inspired to post about w-sitting because of this article I read on the most recent PawPrint Newsletter.  I am going to paste the article in its entire form since I believe Why reinvent the wheel!  She said it great!

The W’s of W-Sitting

Deanna Macioce, MS, OTR/L

We have all seen those toddlers who are playing with cars or dolls in the common position of “W-sitting”.  And since we see it so often in young children, we may not see it as worrisome, however for many children if left unaddressed long-term “w-sitting” could lead to some overall developmental issues.  With that said, this month’s focus is not to alarm, but to increase an awareness while providing some useful and tactical information for parents, teachers and therapists of the many children who find the position of “w-sitting” comfortable.

Although this is a common position to find a toddler sitting in, it comes with many implications of why it is not good.   For those children who move in and out of the position for short periods of time, it can be looked upon as just a typical playing position that the child will outgrow.  However, for many of the children we see in the therapy world, it can have a greater effect on a child’s overall development  “W-sitting” inhibits exploration, does not allow for proper strengthening of the trunk, and keeps children confined to play only in midline. Effects of long-term “w-sitting” include hamstring tightness and tibial torsion and even hip dislocation. In addition, because it inhibits trunk rotation it also causes overall decreased balance and trunk control.  The lack of trunk mobility causes children who utilize this position on a regular basis the inability to cross midline and explore as much during play.

One of the most common reasons children hang out in this position is low tone.  Early on when children begin to crawl, you often find them stopping in the “w” position regardless of tone issues because they require a wider base of support at this stage.  However, as they get stronger, you should be able to see them transition into a proper ring sitting position with ease.  For the children who present with lower tone, they still require a wider base of support and will utilize a “w” due to ease, comfort, and stability.  In addition, many of the children who do “w-sit” also present with tighter hamstrings, making it difficult and uncomfortable to sit in long sitting, “crisscross applesauce”, or ring sitting.

Ways to naturally work on correcting this it to utilize a toddler chair for sitting activities as much as possible, encouraging a 90-degree position of the hips and knees. When using larger chairs where the child’s feet do not touch the ground, the use of a stool will help obtain this position.  Many children will be able to correct this position with verbal cuing, so you may often hear a parent, teacher or therapist use the phrase, “fix your legs” to cue the child to choose a different sitting position.

Ultimately, to help children move out of this position, choosing activities that strengthen the trunk and improve overall stability are beneficial.  Those would include things such as the use of an exercise ball, yoga, and balance activities.

Exercise/therapy ball activities are great for trunk strengthening; from performing activities while sitting on the ball that encourage trunk rotation to using the ball for completing sit-ups, these are excellent ways to engage trunk muscles and work on balance.  Activities performed in high kneel, such as drawing on a draw erase board or completing a bean bag target throw activity will also nicely engage that trunk muscles for strengthening.  In addition, using a balance board for activities in sitting, such as completing a puzzle, or standing to play catch or Zoomball will also achieve this.  Kid yoga programs, including Yogarilla from Super Duper are a fun way to introduce children to the overall core strengthening and attention improving art of yoga.

For those low tone children with tight hamstrings, performing leg stretches or utilizing target toss activities with obtaining bean bags from the floor or low stool with straight legs will help to loosen up the muscles.  In turn, you find children are able to maintain the position of “criss-cross applesauce” with more ease.

Therefore, although “w-sitting” is very common among all children, similar to nail biting, it is one of those habits that if addressed early can really making a difference in overall development, especially for children with lower tone.

Gyro Bikes – aka ‘The Magic Bike’

At our clinic we are very bike friendly and pro-biking (not that you would know it from all the complaining I do when I’m on my road bike!) and recently we had the opportunity to try out the gyro wheel while working on bike riding with our kiddos.  We have been using the gyro wheel for a few months now and love it!  Myself and the therapists I work with are big fans of bike riding (see our prior post ‘Bike Riding‘) because of the way it impacts and improves motor planning, strengthening, balance, reciprocal lower extremity activation, endurance, overall fitness and most importantly because it is a great age appropriate social skill!  Since using the gyro wheel we have been able to progress a greater number of children onto a two wheeler without training wheels.  We call it ‘the Magic Bike’ and the kids love it.  My criteria for progressing them is that they already know how to pedal a two wheeler with training wheels such that they can propel the bike independently on level ground.  This means that they already understand how to pedal and can maintain constant pedaling without help for a decent distance.  This is important, not just for using the gyro bike but also for progressing off of training wheels because the kids are already focusing on keeping their balance, steering the bike and making it go, they don’t need to add in figuring out the mechanics of pedaling.  By using the gyro wheel I have been able to decreas the strain on myself as I assist the child in maintaining their balance and forward momentum.  In addition, they are able to begin riding short distances without my physical assistance significantly sooner then they would if we were to just use their standard two wheeler.  I work with a lot of kids with coordination challenges and overall low muscle tone and weakness.  These add to their challenges of mastering a two wheeler so having the assist from the gyro wheel allows them to fast track their success and increase their confidence and independence.  I highly recommend the use of this device, especially for children who have physical challenges that can impact their ability to achieve independent bike riding in a timely manner.

Things to look for when buying kids shoes

When buying shoes for your child there are a few things to consider.  In this post I’m talking about shoes they are going to wear the majority of the time.  Those special occasion shoes don’t fit into this category!

You want to have your child try on the shoe to make sure it fits.  If they use inserts or braces on their feet, make sure you have the braces/inserts with you so that you get the best fit.  Sometimes you have to take the insole out to give a better fit.

Beware of big toe boxes on shoes.  This can cause your child to turn their toes in more (if they tend towards this pattern already), and it can also increase tripping.  If you watch your child walk and they don’t seem to have any problems then this is not something you have to worry about.  Just be warned that walking on a flat surface usually found in the shoe store can look very different than walking over uneven terrain such as grass or sand and your child’s walking may change.  This is why its always a good idea to make sure the shoe store you buy from has a good return policy!

Make sure there isn’t a lot of space on the sides of the shoe where your child’s foot can wiggle.  This creates instability especially for those kids who are low tone or have some difficulties with walking.  You may need to ask your shoe store if there are shoes that come in narrow sizes so they have a snug fit all around.  It makes it that much more difficult to maintain balance and form if you have to carry a shoe around but your foot can’t stay stable in the shoe.

Look at the weight of the shoe.  Some shoes are heavier than others and this can be a good thing but you need to see how your child responds to it.  You can also find nice sturdy light weight shoes too if your child can’t handle the weight of a heavier shoe.  If you aren’t sure and you don’t feel like you can tell when you watch your child try it on, see if you can get both pairs and have your physical therapist look at how they are walking and give you input.   You may also want to ask their opinion before you go shopping because they may be able to steer you towards brands and styles that they have experience with and know will work well with your child.

Just a few things to consider when buying your child’s shoes!  Of course I didn’t even cover personal preferences such as color and light up and such!

Growth Spurt

Since Spring is a time of growing I thought I’d talk a little bit about kids and growth spurts.  Many of you may remember your adolescent years when all of a sudden you seemed to be all arms and legs and were tripping over your own feet.  Well that was because your body grew a lot in a short amount of time and it hadn’t caught up to where everything was again.  We take in information all the time that tells us where our body is so that we can move through the world.  Three ways we take in information is through our vision, our vestibular system and proprioception.  The quick version of vestibular is our inner ear that keeps track of where our head is and sends messages to the brain.  When you go on spinning rides or spin yourself around until you are dizzy that is the system that you are sending information to.  Proprioception is information that comes through our joints and muscle attachments that tell about where parts of your body are at any given time.

When a child grows they need to adapt to their new size and this involves recalibrating the information receptors that are passing signals on to the brain.  Generally this happens in a fairly short amount of time and doesn’t cause too many problems.  For kids who are already having challenges moving it  is important to keep them moving and practicing skills (even if they already know how to do them) so that their body can begin to make the adaptions to their new size.  Without practice they run the risk of regressing and having difficulty with a skill (such as walking) that they may have already mastered.

In addition to having trouble with proprioceptive information you may see some more tight muscles.  When they grow the muscles stretch and if they have a tendency to be tight or had been tight in the past then they may get tight again.  Although stretching is important all the time it can become even more critical during periods of growth so that they don’t lose range of motion.  You may want to consider talking to your physical or occupational therapist about ways to help maintain range of motion during these times of growth so that you aren’t spending your whole day stretching.  Maybe its using a stander or getting creative with sitting options so that your child doesn’t even realize they are being stretched!

Lastly, for kids who have underlying weakness or who have to work to maintain strength, its critical to work with them during their growth spurts because they will appear weaker due to the new length of their muscles and they bodies.  For kids who are working and ‘strengthening’ on a regular basis they can generally prevent major losses in strength or get the strength back much quicker than kids who have not been receiving active therapy or doing a regular home exercise program.

Basically, the take away is to pay attention to if your child is growing because you may see some changes in their abilities to perform skills and movements that you thought they had already achieved!