Tuesday 11 October 2016

Home Chores—Essential functional training!

A few observations on children in my clinic compelled me to start this interesting topic. Many young children (ages 5 to 10 years) who are on therapy for improving core strength, attention, and handwriting have difficulty with bending, squatting, floor-sitting, and holding an upright chair posture. Surprisingly, they do not present with significantly low muscle tone or weak strength that would seem to negatively impact their function. On careful review of their lifestyle, it dawned on me that despite being enrolled in structured extracurricular activities, these children do not have any opportunities to participate in home chores. Since extracurricular activities occur on a daily basis after school, there is a rush to reach somewhere all the time.  Children also complain about being tired, or sound irritable and angry very frequently.  These behaviors seem to be a consequence of no time for free play when they can exercise their bodies—bend, twist, roll on the floor, run freely, climb short heights and so much more. Unfortunately, screen gadgets also contribute negatively to child behaviors and lifestyle.

Besides free playtime, home chores is another form of physical exercise that additionally teaches responsibility. These are home activities like cleaning, wiping tables, chopping vegetables, setting the table, throwing out garbage, doing dishes, making yourself a simple snack, and the list is endless. Activities can be age- appropriately taught and assigned to children as young as 2 years old.  

Each of these chores offers a variety of movement that is essential for motor learning that further leads to structural changes in the brain. Moreover, all of these chores provide sensory input to our nervous system that is so necessary for our well-being.
Pulling out wet clothes from the washer---provides tactile and proprioceptive input.
Drying wet clothes on a clothesline—motor planning, strengthening of arms in addition to tactile, proprioceptive, and vestibular  input.
Chopping vegetables—proprioceptive and tactile input to the hand and fingers thus contributing to fine motor skills.
Bending over repeatedly to pick up objects from floor—vestibular, visual, and proprioceptive input.

Home chores are meaningful and functional with each one being a goal in itself.  It is well known that goal accomplishment is a reward that boosts confidence and self-esteem. Due to the inherent nature of these tasks, they create opportunities to move our head and body segments in infinite ways. Additionally, they require problem-solving to a large extent.
What size container will you choose to take out leftovers?
How are you going to move your bucket full of wet clothes—by carrying, pushing, or pulling?
How do you  fold towels of different sizes?
How do you hold 2 ends of a garment and hang it on a line?
Do you need to scrub a surface or just wipe it lightly?
What body movements can be used to carry things from the car to the house?
What is the best way to pull the suitcase during travels?

Variety of movement and problem-solving are the key ingredients to cause structural changes in our brain. Variation in movement helps integrate our senses, thus leading to efficient functioning. Movement is life and life is all about  a variety of movement.

In our quest to have our children accomplish so much in a single day, we are forgetting the critical healthy option, which is to physically use our bodies to accomplish a meaningful task. Our children are always engaged in activities rather than learning to solve problems and challenge themselves functionally. The daily routine is devoid of the sensory input that is so essential for the development and nourishment of our nervous system.

Children do require sports and organized activities; however, balancing them with chores and tasks around the house goes a long way in improving their attention, problem-solving, and realizing their share of responsibility.
A longest Harvard study  has concluded that children who have participated in house chores tend to live successful professional lives as adults.

Some age-appropriate chores for children as follows:
2-3 year olds
Pick up toys.
Dust with a rag.
Collect dirty clothes.

4-5 year olds
Set the table.
Put away clean silverware.
Straighten books on bookshelf.
Sweep kitchen with small broom.
Wipe tables.
Fold towels.
Water plants.
Bring things from car to house.

6-7 year olds
Sweep floors.
Fold clothes.
Take out wet clothes from washer.
Wash light dishes.
Help parent in preparing food.
Take out garbage.

10 year olds
Mop floors.
Help supervise younger siblings.
Tidy bedrooms and kitchen.
Help with cooking and baking.

Pushing around small furniture.

Thursday 12 May 2016

Torticollis


Congenital muscular torticollis (CMT)  is a congenital deformity of the neck, seen in a baby as head being turned and / or tilted to one side. There have been 3 sub types of torticollis:
  1. Tumor in the sternocleidomastoid (SCM) in terms of a discrete mass  palpable in the muscle.
  2. Muscular torticollis where there is only tightness of the SCM. but no palpable mass.
  3. Postural torticollis when there is neither SCM tightness nor palpable mass.

X-ray will be normal in all 3 subtypes, however, ultrasound should detect dimensions of  a palpable mass when present.
Postural torticollis maybe due to one of several reasons including positioning, congenital absence of a cervical   muscle, or tightness of other neck muscles.
Stretching of Right SCM with Gentle Neck Traction

Stretching of Right SCM on a Therapy Ball
 This blog will discuss 4 children with torticollis who were treated in my clinic in the last couple years.
  1. A baby boy of 10 weeks presented with a palpable mass in the right SCM. The mass was detected during the second week after birth and PT intervention was initiated in the form of neck range of motion (ROM) and positioning.  However, parents were concerned about lack of progress or rather worsening of the neck posture as weeks elapsed. Hence they approached me for a second opinion.
    Treatment was provided in the form of stretching with gentle neck traction and positioning in the initial few sessions.  Very soon,  prone positioning was  introduced  and  parents were provided ongoing instructions about correct  handling of the baby.
    Parents started observing changes, the baby started feeding on both breasts, and neck posture was improved. 
  2. A newborn of 10 days old presented with a small palpable mass that was resolved within the next 3 weeks of treatment and full ROM was achieved.
  3. A 6-months old baby with a diagnosis of developmental delays presented with asymmetrical  posture. He would only look and turn towards his right. When passively turned towards the left, he would scream despite apparent full ROM. On visual observation, there seemed to be hemiparesis of the left side. However, on careful examination, tightness of the left upper trapezius was revealed. This baby had a postural torticollis with concordant plagiocephaly. 
    Again, intervention resolved most of the asymmetry within 10 sessions, and further treatment was geared towards achieving developmental milestones.
  4. Another 8-months old baby girl presented with tilting of the head to the left.  The persistent head tilt was first observed at 4-months of age; mom remembered that the baby preferred feeding on the right breast during early infancy. Ultrasound had revealed neither mass nor tightness of the SCM.  Developmental milestones were age-appropriate, inclusive of bringing hands to midline and reaching with the left hand.
    On examination, there was tightness of left upper trapezius and surrounding soft tissues. Hence a diagnosis of postural torticollis was provided. There was insignificant plagiocephaly.
Active reaching to the right.
  • The common factor central to treatment of all these infants was stretching of the tight neck muscles after gentle manual traction of the neck. 
  • As treatment progressed, other treatment components such as prone positioning,  crawling, reaching, and many other activities were included to develop midline head control and righting responses on the involved side.
  • These activities were also targeted to prevent neglect of the visual field and the involved   side of the body.
Crawling up a slope while encouraged to rotate head to right.

Encouraging head control on unstable surface.
 Research has demonstrated a correlation between severity of restriction in ROM and treatment duration towards achieving full ROM. Only one of these babies had to undergo surgical SCM release at 2 years of age since contralateral head tilt was minimally achieved and the SCM presented as a restricted band despite 5 months of conservative management. Otherwise conservative treatment was successful for the other 3 children.

 The key to success of conservative treatment is to commence treatment as early as possible. Generally, ROM is achieved fairly well if treatment begins within 4 months of age. If left untreated, CMT can result into ipsilateral neglect, disuse of the involved side, cervical scoliosis, and pelvic obliquity.



Reference:
Campbell , Linden, Palisano (2006); Physical Therapy for Children, Saunders Elsevier