Using a Treadmill for Walking Quality

In last week’s post we talked about weight shifting and trunk elongation to help walking quality and energy efficiency. This week we are going to look at using a treadmill.

For some kids who are working on walking quality and efficiency foot placement can be a big deal. How they take that first step can affect everything else that goes up the chain to the hips, the trunk, and the head. By using a treadmill you can slow down the speed so they have time to think about what they are doing and get in a lot of practice and repetition (remember: repeat, repeat, repeat…). We also added tape down the middle to help provide a visual cue for foot placement to help decrease scissor stepping (when feet cross over midline while walking instead of going straight in front).

We also provided a wooden dowel in front to provide some balance assist (but with only 1-2 fingers resting lightly so they aren’t leaning on it). With some verbal cues for heel to toe foot placement, and the light support at the wooden dowel to help keep the trunk upright, it also helps to prevent other compensations that can occur from underlying hip weakness such as internal rotation at the hip to lock out the joint and create stability. But it also creates a crouching pattern that decreases efficiency and energy conservation with walking.

We are lucky enough to have access to a treadmill that can start at really low speeds. We did 2-3 minute increments of walking, over 4 different speeds, twice at each speed. As we were building up occasional manual cues were provided to assist with weight shifting, as well as pelvic and trunk rotation. After we got up to the highest speed we were going to, we went back down to the slowest, and repeated 2 sets at that speed without any manual cues. Afterwards, we went to overland walking. Since it still isn’t automatic (remember it takes lots of repetition to make it automatic) there were lots of verbal cues to slow down the walking rather than go back into the habitual walking pattern that automatically arises when they aren’t thinking about each step they take.

How have you guys used a treadmill to help walking quality?

Weight Shifting and Trunk Elongation

 

We have been working on walking with some kids that are working on improving their weight shifting and all the mechanics that go with that. Many of them have hip weakness which we are addressing but we are also looking at other areas to address as well. With the hip weakness you can often see a trendelenberg pattern (when their hip drops on the leg they pick up to take a step with). One way kids counteract this is to lean their trunk towards the side that they are standing on when they pick up their other foot to take a step. This provides them some hip stability but it decreases their efficiency and increases their energy utilization because they now are actively moving their trunk side to side with every step. It also makes it harder to fix on a target when walking and can cause path deviation.

So, we decided to help them work on elongating their trunk while weight shifting onto the stance side. To do this, we used a balance board to simulate the weight shifting. As their hip strength and overall balance improves we can take the balance board away and have them shift into single leg stance but for now we decided to only add one new challenge to the task and let them keep both feet on a support surface. We placed a target above their right side and their left side that was just high enough for them to reach when they reached overhead.

Once we were set up, we asked them to shift over to one side and at the same time reach overhead to hit the target. This resulted in them lengthening their trunk on the side they were shifted to (as opposed to shortening their trunk because they were leaning to that side). Once they hit the target they shifted over to the other side and repeated the process over there. We did this in sets of 10. After that we did some overland walking with light tactile cues at their hips and verbal cues to reach overhead when they were on their stance leg.

Did it miraculously change their walking? No, but it started to introduce a new motor pattern that will require a lot of repetitions to become second nature, and it will require continued strengthening of the hips. But it is another component to helping with a more energy efficient walking pattern! Just remember, it takes lots and lots of repetitions to change a motor pattern – repeat, repeat, repeat…

What ideas have you tried?

The Power of the Calves

I don’t know about you, but I have had many children over the years that really struggle to use their calf muscles in an efficient and effective way. This could be due to many reasons but there is probably some underlying weakness and coordination challenges. I have seen this a lot in my kids who are toe walkers. Now I’m sure some of you are saying ‘wait but they walk on their toes, doesn’t that mean they use their calf muscles and they should be nice and strong?’

Not necessarily. Because they tend to walk on their toes (this may look like they are up high on their tip toes or it may look like a shuffling walk with the foot mostly flat but never getting a heel strike first) they aren’t moving through the full range of motion at their ankles and so their calves are only working in a very small range. For the kids up on their tip toes they are really strong in that one position but they would fatigue pretty quickly if you were to ask them to do multiple heel raises in a row. For kids whose feet look flatter but they are still not hitting with their heels first, they are tending to constantly stop a ‘fall’ forward by catching themselves on their foot and then ‘falling’ forward onto the next foot. They aren’t using their calves to help them push off to lead into the step, but rather ‘falling’ into the step.

So as you can see calves work in two ways, they help to control your step forward by supporting your body weight as the muscle slowly lengthens, and they also help to push off by shortening the muscle to give you power to go into the next step. These are also helpful for jumping and running activities to name a few.

Hopefully all this is making sense. I really started this post to give you some ideas for how to work on the calf muscle to help your kiddos use them more effectively and efficiently!

• Scooter Board Push – I was inspired when I came across this post. I have a few kids that I have been trying to get creative on ways to work on their calves. I actually tried this one out and the kiddo I was working with loved it! He loves to do puzzles so we put the puzzle pieces on one side of the room and were assembling it on the other side of the room so he had to push me back and forth to get all the pieces. Because of the size of the room we had some extra challenges because he had to turn a corner as well causing him to work on his motor planning. In the beginning he had some trouble and would try to go down on his knees to push or I would help him too much so he was just walking and not pushing through his feet but he eventually got it and was so excited when we would get going fast and when we could turn the corner without running into the crash pad! I completely recommend this activity. Just an FYI, carpet causes them to work harder!
• Wall Push Offs – You can do this one on a scooter or a swing. With a scooter you can have competitions to see how far you can push each time and if you can get further than your last time. Or you can set up bowling pins that when they push off the wall they have to try to knock them over and see how many tries it takes before they’ve knocked them all over. You could also use an exercise ball and have them push off of that and see how many pushes it takes to get down the hallway, and then try to get fewer pushes on the way back! Obviously you would have to move the exercise ball to them each time and hold it stable while they push.
• Furniture Gliders – With the smooth side down on the furniture gliders, have them put their hands on the top side. Then create a course with painters tape and have them push their hands all along the path. The key is to make sure they are pushing with their feet and not dropping down onto their knees. You can change up the course and make it straight lines, curved lines, zig zag lines, or have it be a treasure hunt/maze where they have to follow the lines to get to bean bags or puzzle pieces and then they bring them out of the maze before going back in to collect the next one! If you don’t have furniture gliders you could do this with bear walking but its definitely more fun with being able to push yourself around! You could also try putting their hands on a scooter and pushing that way if you don’t have furniture gliders!
• Step Downs – Stepping down slowly really helps to work on having the calves control the body weight as it lowers down. That being said, this is often hard for kids to control. We have tried putting a stomp rocket on the ground below the step so they have to step onto the stomp rocket to get it to go. If possible I recommend doing this without rails. You can change the height of the step to make it easier or harder. And the kids love to shoot the stomp rocket. We generally have targets that we aim for. You can give points to each target and have them try to get a certain number of points by hitting them with the rocket.

What are some ideas you have for calf strengthening with kids?

Encouraging Independent Exploration

As a pediatric physical therapist, one of the things we hear the most from parents is, ‘I want my child to walk’. And this is completely understandable.  Its how we get around, how we explore the world. However, what if walking limits the child’s independence?  I’m not here to say what is the right way to do things and the wrong way to do things but just to raise some things for families to ponder as they continue to support their child’s growth and development.

Children are always interacting with the environment.  When they are really little they are limited with their abilities.  Mostly its what is brought to them or what they can see from their current position.  As they grow and get stronger, most kids start to develop some independent movement.  That could be rolling, getting into sitting, scooting, crawling, pivoting, standing, cruising, walking, etc.  Each change in movement and ability changes their perception of their environment and how they interact with that environment as well as the people around them.  For the first time they can see something and figure out how to get there if they want to learn more about it.  Its amazing how resourceful kids can be when they want to be.

For kids who have delays, for whatever reason, independent exploration can be hard for them. They are often dependent on others to get them from one place to another, or to bring the world to them.  What if we could work hand in hand with them to discover alternative methods of having the independence to explore their environment or move without anyone’s hands on them, while at the same time continuing to promote their gross motor abilities.  There are some great tools out there that can increase mobility for kids, from an early age.  While I know using assistive devices or wheeled mobility is not for every child or family, it is an option to give them that independence while their other skills are still developing.

I’ve linked to some resources above, but one of my favorites is the work of Go Baby Go and their use of powered kid cars that have been adapted with increased support as well as switches to make them go.  The kids love them!

I would love to hear from people about their experiences with using early mobility to increase independence vs focusing only on gross motor milestone development.

 

 

 

To Flip-Flop or Not

So, you’re in the department store shopping for your kid, because they seem to be growing every week! They are in dire need of new shoes and it’s summer, which means it’s flip flop weather, right?!

Not so fast! Although, I love the cute sandals they have for kids now a days – I think it’s important to look at how sandals may be effecting your child’s walking.

When you think about how a tennis shoe is secured to your child’s foot and then think about how a sandal is secured to your child’s foot – they are very different. When you’re wearing a tennis shoe you don’t have to think about keeping the shoe on your foot, which allows your walking pattern to be similar to how you would walk barefoot.

Now, when you’re wearing flip-flops, you have to secure the shoe on to your foot by gripping your toes into the sandal. This creates some confusion for your body. As you’re swinging your leg through, your hip is moving up/forward, but your toes are pushing down trying to keep the flip-flop onto your foot – do you see the confusion? Not only is your body confused, but by gripping your toes onto the sandal it places pressure and tension onto parts of your lower leg and foot that were not intended for that purpose.

But it’s hot out and my child and I need summer shoes! Consider a shoe that is secured to the foot – something that cups the heel. It can have straps and openings, but when the shoe isn’t secured to the foot such as flip-flops and slippers – it places abnormal pressure and tension on your child’s body.

Just some things to think about as you are buying your next pair of summer shoes!

Football Fun

  

In honor of Super Bowl 50 being in the San Francisco Bay Area next weekend, and the Broncos playing in the game, I thought I would share a football activity one of our therapists came up with. She used this as a motivating activity for one of our kids who is really into football and wanted his therapy activities to be meaningful.  I thought she did a great job of incorporating his age appropriate interests into something that was therapeutic and fun.

As you can see from the picture a football field was created along with goal posts.  This child was working on dynamic standing and sitting balance as well as walking, transitioning between sitting and standing, and squatting to pick things up from the ground.

With this set up his goal was to get it through the uprights. He got a certain number of points based on various criteria

• Was he sitting or standing while he threw the ball
• Did it go through the uprights
• Did it land on the ‘field’
• How far away from the target did it land

Clearly if he threw it standing and it went through the uprights he got the most points and then they were graded lower after that.  He had a target number of points that they kept on a white board (also allowing him to work on his math skills!).

After he threw the ball he had to walk to where it landed (or to the accessible place the therapist moved it to) and squat down to pick it up and then return to the bench and sit before he threw the ball again.

You could easily do this with bean bags or a soccer ball and goal or any other activity.  The part that was fun for us was all the skills he could work in a meaningful and fun way for him!  And, football was a regular discussion with regards to players, positions, teams, divisional standings, etc.

What ways have you made activities meaningful for your kids you work with?

Which Shoes Are Best?

As parents, you may wonder what is the best product or toy that will help your child meet their milestones or learn things quicker. I’m sure you’ve also wondered what type of shoe could be best for your new walker? There are so many shoes to choose from that will help make your child the most fashionable, but which one is going to be the best for the development of walking? There is not one right answer, but here are a few things to keep in mind when choosing a shoe that will be right for your child.

As children learn how to walk, their foot plays a huge role in their stability, shock absorption and momentum. The bottom of their foot allows them to feel where they are in space. Therefore, the type of shoe that is worn can determine their walking pattern and stability. Should your child go barefoot, wear a flexible shoe, or stiff shoe?

Some research shows (see below) that the best foot development occurs when a child is barefoot, so the best shoe would follow the barefoot model, meaning that the shoe should be flexible. Going barefoot allows the foot to feel the texture of the floor and gives them good sensory feedback to let them know where they are in space. A flexible shoe (soft material with a soft sole that allows for bending) can also allow for more sensory feedback, similar to going barefoot. However, a stiffer shoe can lead to greater stability compared to a very flexible shoe. It was seen that children keep their foot on the ground for a longer period of time when wearing stiffer shoes, possibly because they are not getting as much input and need that time to understand the environment that they are in. So if your child seems to be a little more unstable, a stiffer shoe may be best for them.

Depending on what type of shoe you decide to put your child in, they typically will adapt to it and change their walking pattern (amount of time they keep their foot on the floor, width of their feet, and speed of walking). Children are fast learners and are ‘flexible’ to any changes that come their way. As therapists, we are always trying to promote adaptability; so changing the type of shoes that they walk in can be a great way to teach them how to experience a new situation. As mentioned before, there is not one perfect shoe for all children and the need for flexibility vs. stability may need to discussed further depending on your child’s needs.

Keep in mind that the articles referred to focused on children who are developing motor skills typically, therefore, the amount of stability or flexibility may depend on the individual need of your child.

Buckland MA, Slevin CM, Hafer JF, Choate C, Kraszewski AP. The effect of torsional shoe flexibility on gait and stability in children learning to walk. Pediatr Phys ther. 2014; 26: 411-417.

Staheli L. Shoes for children: a review. Pediatrics. 1991;88:371

Should You ‘Walk’ Babies?

We have had some families bring this article, 9 Reasons Not to Walk Babies, to our attention.  It was generally a response to some of the things we were working on in therapy with their child, and confusion because this article to them seemed to be saying the exact opposite of what we are asking them to do.  I have to admit when I first read it I thought the author was completely wrong.  Then I took a step back and read it again.  What I realized was that the first time I read it, I was reading it with the bias of how it related to the specific child we were working with.  In actuality, what the author is promoting is independent exploration and development of the child.

I am a big proponent of allowing children the chance to independently explore and facilitate their own motor development as their bodies are ready.  Unfortunately, not all children are able to do this on their own and they need assistance with how to explore and move, and sometimes they help practicing and repeating skills, such as walking, so that they can master them.

Going back to the families that have asked about this article, the challenge was that due to busy lifestyles, other children, and ease of getting around, many of them were using carrying devices like carriers and strollers, or physically carrying or holding their child an overabundance of the time and not providing them the opportunity to explore their environment, thereby limiting their ability to figure out how their body works, trial certain movements, register the feedback, make adjustments and gradually refine their movement until they were masters of the skill.  This is the ideal way kids learn movement, opportunities to practice with trial and error.  By carrying their child everywhere, they were in fact putting the same constraints on their child as this article was attempting to steer them away from.  They weren’t allowing their child to develop at his own rate.

Its interesting that I have read two other posts that talk about the overuse of equipment in society today and how it limits children in this same way.  One was a guest post on our site about avoiding the ‘container shuffle‘, and the other was by Pink Oatmeal on baby items you don’t need.  This topic is also related to the Bumbo Chair.  Again its a convenience that can have specific benefits, but when its used to teach a child to sit before they are physiologically ready, it is not being used to the child’s benefit.  In that same way, when ‘walking’ your child is being used to teach your child to walk before they have even mastered standing, then it may be that they aren’t ready for it.

The best way you can support your child’s motor development is to give them plenty of floor time with the opportunity to explore.  Use yourself or engaging toys to motivate them to move.  If they are trying to move and getting frustrated its okay to give them a little boost, just make sure you are not always doing it for them, their is benefit to not succeeding every time, that’s how their bodies make refinements and adjustments so that they can become more efficient with their movements.

On a slightly different note, but on the same topic, for children who are already experiencing delays for one reason or another, and are engaged in therapies, the therapist may give you things to work on that are meant to support your child’s development because at that time, they are behind and they need that extra push.  If walking is one of them, its probably because your child needs your help in creating opportunities to practice the skill and learn from those trials, and they are not creating those opportunities for themselves.

 

Development of Gait (aka How We Learn to Walk)

 

 

OVERVIEW: Gait is a medical term used for walking.  Often, in a pediatric therapeutic environment, there is an emphasis on independent walking. Most parents understandably want to know when and if their child will be able walk. This is most likely because for most people, independent walking translates to increased independence in other areas of life and therefore, decreases the amount that a person will have to rely on others for assistance. As therapists, we must understand the several factors that affect the development of gait and be able to work towards independence when appropriate but also be able to determine when independent walking may not be the most important and functional goal at a given stage of development.Research has shown that typical walking has 5 major characteristics: stability in stance (when foot is in contact with ground), sufficient foot clearance in swing (when limb is moving through the air), appropriate pre-positioning of the foot for initial contact, adequate step length, and energy conservation.  These characteristics are not present from the moment we take our first steps, which can be anywhere from 9-15 months of age in typical development. They develop over time with growth and maturation. Just as you need prerequisites to advance to higher level courses in college, you need prerequisites to achieve the 5 major characteristics of typical gait.  These prerequisites are adequate motor control and central nervous system maturation, adequate range of motion, appropriate bone structure and composition, and intact sensation (mainly proprioception).  Therefore, in the presence of neuromuscular or musculoskeletal disorders, typical walking may not always be achieved. If all the prerequisites are present, then you should see typical gait, which includes the 5 characteristics listed above, emerge by 3-3.5 years of age.

DEVELOPMENT OF GAIT BY AGE:
Birth to 9 months: During the first few months of life, several things are happening that lead to upright movement.  First, body compostion is changing.  On average, in the first 6 months of life, body fat increases from 12% to 25%.  This increase in fat content makes the infant weaker for a period of time.  In fact, some studies have suggested that larger infants with higher body fat percentage may achieve locomotor milestones later than their smaller friends. As they move towards their first birthday, fat content tends to drop while muscle mass increases and therefore, we see babies getting upright. Second, growth is happening more so in the arms and legs than in the head and trunk. This growth allows the baby to provide a greater resistance against gravity.  Third, the baby is naturally exercising muscles that need to be strong for typical walking.  On their backs, they are kicking which develops antigravity hip flexor strength.  Hip flexors are the big, thick muscles in front of our hips that allow us to pick our leg up and move it forward during walking. On their tummies, they are working out their hip extensors or booty muscles. These muscles work on and off and sometimes with the hip flexors to coordinate smooth walking.  Studies show that antigravity control of movement by these two muscle groups at the hip joint typically develops by 8-9 months of age.  Therefore, the baby may not even be able to stand independently and the hip muscles already know how to control gravitational forces. So, if the baby is moving and growing typically at this point, they are gaining muscle mass, losing fat content, and developing antigravity movement and therefore, postural control.

 

 

9 to 15 months: During this time, the baby is weight bearing more and developing independent walking. They are cruising, which develops hip abductor muscles strength.  Hip abductors are the muscles on the outsides of our hips that allow one leg to stay stable while the other one swings throught the air during walking.  Are we starting to see a pattern…development of the hip musculature is an extremely important precursor to typical walking. As therapists, we often go back and address this if independent walking is present but atypical. Also, during this time, increased weight through the legs changes the overall structure and alignment.  Here, the baby’s legs will begin to straighten out from their previously bow-legged shape in infancy.  If they are pulling to stand they are now performing muscle contraction in a closed chain, which means their foot is weight bearing and they are pushing through their hip and knee to achieve upright.  An example of an open chain movement would be kicking where the foot is not in weight bearing.  Closed chain movements create new demands on muscle strength and ability to move against gravity.

 

 

18 to 24 months: Now that they child is walking independently, you will see the pattern begin to refine. The base of support will begin to decrease because the hip muscles are learning to stabilize within a smaller range of motion. Also, the legs are growing longer becoming the most rapidly increasing dimension of the body.  This even brings the center of mass of the body lower down the trunk allowing for increased stability. Finally, the child is developing more mature strategies for balance and postural control which may result in a more typical looking walking pattern because it involves the ability to anticipate disturbances in balance rather than only react to them once they have happened.

 

 

3 to 3.5 years: If everything has occurred typically up to this point, the structure and angles of joints are maturing in to that of an adults. Balance strategies continue to be refined.  Walking speed normalized for height is consistent with that of adults.

 

 

6 to 7 years: By this time, walking is fully mature. Little comparison can be made to an adult pattern.  The center of mass is still slightly higher than an adult and will continue to lower with growth.

 

 

As you can see, the development of typical walking begins at birth and continues to evolve over several years during times of rapid growth.

 

 

Campbell et al. Physical Therapy for Children 3rd Edition, 2006. pgs. 161-171.

 

‘Lazy’ Feet

One of the things I love being a pediatric physical therapist is when my friends ask me questions about their kids.  I’m sure many may think that’s odd but I love that it challenges me to think and problem solve.  Added to the challenge is that often, my friends live no where near me so I’m getting their descriptions of what their child is or isn’t doing or I’m getting videos of their kids.  I’m not sure how we ever lived without technology!

A recent question was about running.  My friend noticed that sometimes her son ran ‘fast’ and other times he ran slow and awkward.  I had her send me some videos and while I may not know exactly what is causing the challenges with her son, I was able to relate it to some things we’ve seen with kids in the past.

Now I’m making up this term so don’t try to look it up, but kids can have ‘lazy’ feet.  They aren’t engaging their feet and ankles when they are walking or running.  This can cause toes to drag, or them not to have push off, or any other type of ‘odd’ movement pattern.  Now there are kids that have challenges with this because of a physical challenge and that may be a slightly different story.

For kids that just aren’t engaging their calves when they walk or run, they aren’t getting the push off that initiates the swing phase of their walking or running and they lose the propulsion that can set them up to move quickly or smoothly.  In addition, without activating the push off, often they won’t maintain activity in their ankle muscles causing their foot to look floppy as they walk, and possibly cause their toes to drag or their foot to slap down on the ground.

There is no sure fire way to fix this but we work a lot on leaping from one foot to the next, jumping up into the air and emphasizing push off, and telling them to take longer steps (using spots or markers on the ground is a great way to encourage this).  Each kiddo is going to be different but if you think your child needs a little boost to their running, help them to wake up their calves and other foot/ankle muscles.  They can also walk on their heels, walk on their toes, hop on one foot, etc.  After doing this have them practice running.  Also, if you play ‘chase’ you may see their form improve because they are trying to run faster which can encourage longer strides and an improved push off.

Also, you will see better form on a firm surface than if they are on sand or in long grass.  So start on a track or road/sidewalk and then progress to the more challenging surfaces like the beach or your yard (unless your grass is cut really short).  Also, wearing running shoes or bare feet will potentially show better form than looser fitting shoes like clogs or flip flops.

I just thought it would be fun to share some observations that I’ve noted and see what others think on the subject.