W-sitting

 

W-sitting is an ATYPICAL way of sitting on the floor;  the buttocks rest on the floor while the lower legs point outwards and back.  Toddlers and preschool kids are often seen in w-sit position while playing with toys. For the child, it is a stable position and hence w-sitting becomes a habitual behavior quickly. 

If a child w-sits for prolonged periods of time, the consequences would possibly be any or all of the following:

Hip joint distortion—muscles and soft tissues on the medial aspect of the joint would be hyper flexible, whereas the same on the lateral aspect of the joint would be tight and contracted. 

Knee joint and feet distortion—the abnormal position of w-sitting would naturally place the knees and ankles in an abnormal position with similar consequences as the hips. 

Pigeon-toe gait---the distortions at the hips, knees, and ankles lead to in-toeing or pigeon-toe walking. This gait deviation does not only matter cosmetically, but leads to abnormal bone development of the lower leg.

Core muscle stability—remains  under developed  as a result of prolonged w-sitting position, since the muscles of the abdomen and back have to work minimally during w-sitting rather than being challenged. 

Crossing midline and Bilateral coordination—remain poor secondary to lack of trunk rotation that characterizes w-sitting. 

Conversely, if a child is frequently observed to w-sit, one or more of the following could be suspected:

Increased internal rotation of the hips.

Laxity of the hip joint ligaments.

Low muscle tone.

Children with neurological conditions such as cerebral palsy,  hypotonia, autism, and ADHD are highly likely to assume the w-sit position. They should be encouraged to sit in cross-legged or long-sitting positions during floor time.  Tall -kneeling is another position that can be encouraged during table-top activities. Otherwise they are at risk of learning higher functions that involve reaching, manipulation of objects, as well as writing.

Therapeutic Use of the Forgotten Board Games

Snakes & Ladders is an ancient game of India that probably provided a moral lesson of life’s ups and downs as per virtues (ladders) and vices (snakes) respectively. There is a simple colorful grid of numbers 1-100, with a contrast of snakes (live being) versus ladders (inanimate gadget) drawn on it in a particular fashion and in different sizes. Its Western counterpart is Chutes & Ladders.

Growing up in 1970s India, abundant time was spent on playing three common board games, the Snakes & Ladders, the Ludo, and the Business. These games helped us to practice math learned in school and taught emotional regulation when your own token piece was not moving forward or had to come to a lower value number on the board.

As therapists or any professional working with children, we are aware of how challenging it is for a child with special needs to translate therapy and classroom gains to the external environment.

Therefore, I made a concerted effort to introduce the Snakes & Ladders to children in my clinic who were about 5-7 years of age. These are children who loved to work with any activity that included numbers. Over time, when their readiness to participate and engage with another child improved, and they had mostly overcome their rigidity or obsession with numbers, they were ready for their first board game of Snakes & Ladders.

Despite children being good at numbers 1-100, it came as a surprise to moms that the game was not as easy for their child. We came across the following challenges –

Taking Turns

For most young children, waiting for their turn is always a work in progress with any new activity.

Using Hands for Tiny Objects (dice)

The concept of rolling and throwing the dice had to be taught using cupped hands joined together.

Visual Recall and Working Memory

Remembering your own token piece and its position on the grid during their last turn needed verbal cues from an adult. Visually counting the number of dots on the dice and moving the same number of squares on the board required significant help.

Visual Sequencing and Directionality

Continuing from their last position was again a different concept for the child, i.e. sequencing from the number that they were on their last turn.

Sense of directionality while moving the token piece in increasing order of numbers was another difficulty. Their instant reaction was to move the token piece in any direction – backwards, forwards, or upwards. Although the child is good at numbers in terms of recognition and sequencing verbally, following the correct direction on the board becomes a challenge.

Moving from left to right in one row versus right to left in the immediate next row was difficult to comprehend.

The concept of going up the ladder or coming down the snake had to be reiterated multiple times. Some children initially had an emotional issue while coming down on the snake, hence this rule needed to be ignored for the time being.

Task completion

Patience to complete the game required sustained attention, and going up or down helped work towards building emotional control.

Take Away

In summary, Snakes & Ladders is a simple game that can be introduced in sensory motor therapy and can be continued with the child at home. It offers significant therapeutic value to children with special needs to boost working memory, vision-perceptual skills, and generalization ability.

The same goes for Ludo or Pachisi or Parcheesi which can be introduced after reasonable comfort with Snakes and ladders. The Business is another board game if parents wish to teach counting and exchanging money to a child.

These simple board games may look unappealing in this fast-paced, digital world. Once we understand their impact on family bonding and applications to the real world, they become indispensable.

Sensory-motor therapy: How much, when to begin?

Most clinicians recommend starting therapy as early as possible when a neurological diagnosis is confirmed or the child presents with obvious deficits in speech, motor skills, and behaviors. However, the glaring questions remain….

• ·       How much therapy i.e. how many sessions/week, how many months?
• ·      And more importantly, will the problems be solved or cured completely?

The following factors play a major role in deciding the frequency of therapy and how long will it be continued:

Age at which any intervention was first begun—most children with special needs undergo various therapies such as physical / occupational / speech therapy, and applied behavior analysis (ABA). The earlier you seek intervention as soon as you sense that all is not well with your child, better is the child’s prognosis.

Children learn through movement. When attention is brought to movement, the brain creates new connections about 1.8 million new connections per second. In the first 3 years of life, the brain grows four-fold, reaching 80 percent of its adult weight. The increase in size is due to an increase in number of connections between cells. From these connections, re-organization of the brain occurs in terms of body mapping, movement mapping, cognitive and emotional organization. At age 7 years, the brain of a child looks like an adult brain. Of course, it keeps modifying itself throughout life, but the maximum number of connections between neurons (brain cells) are developed and strengthened until age 6-7 years. Therefore, the need for sensorimotor intervention as early as possible.

In my long clinical experience, increasingly negative behaviors (defiance, reluctance, unwillingness to engage in effortful tasks) have been observed around age 4-5 years in children with autism and hyperactivity. This occurs not because the issues were not present earlier; but have surfaced with greater intensity because the child is placed on demand as he/she grows up. Therefore, it becomes an uphill task in therapy to get them to engage in meaningful work.

Other factors that go along with the diagnosis or deficits--- there are inherent features of every condition that are unlikely to resolve completely. For e.g. spasticity, severe hypotonia, athetosis (involuntary shaking), tightness/ shortening of muscles are seen in cerebral palsy. Deficits in spontaneous speech, echolalia, stimming behaviors are signs of autism. All of such signs and symptoms can be resolved to a large extent ‘if’ intervention has commenced early in life.

This treatment journey with your child is unfortunately a long and hard one; there are no quick fixes nor 'cure' despite the best treatment in the world. The underlying purpose for sensory integration and speech therapies is to improve the child's functional capabilities as much as possible. 

Typically, any child with special needs requires 1-2 years or even longer for therapy. The frequency of treatment would be 1-3 times per week based upon clinical findings as to how much potential is seen for improvement. During a phase when the child ceases to demonstrate adequate progress, therapy is discontinued with recommendations to continue with a home program.

Level of Cognition---is highly corelated with our comprehension of the world around us. If a child understands the verbal / nonverbal cues from another person, if he /she comprehends the affordances of objects in the environment, progress in therapy occurs at a faster rate.

It is crucial to remember that movement contributes to cognition and vice-versa.

Other concomitant therapies---Speech therapy received along with sensory integration (SI) works wonders for children with autism and ADHD. SI provides the groundwork for understanding the sensory stimuli around us, whereas speech therapy helps develop the tools to communicate. Even if the child is nonverbal and has minimum potential to develop speech, speech therapy still helps in comprehension of instructions and pictures. For a child who is already speaking only a few words but has deficits in spoken language, speech therapy helps in development of contextual speech that immensely boosts communication with others.

Support at home—parents need to follow the home program and strategies with the child as a carryover of therapy at home. Therapy sessions from all interventions amount to only 4  to 10 hours per week. This time is insufficient if we consider 12 hours of wake time X 7days = 84 hours. The brain is continuously modifying itself (neuroplasticity) based on opportunities and experiences that the child is provided with.

Accepting your child’s condition avails you of more energy and ideas towards the child’s progress rather than being in denial for a long time.

And finally, when you have doubts about the cost of therapy (time, money, effort), it is compelling to ponder about what would be the costs of not opting for therapy:

• ·       deficits in function
• ·       deficits in speech
• ·       deficits in learning
• ·       negative behavior issues
• ·       increase in restlessness or hyperactivity

Therapy will only ENRICH your child’s life!

Develpoment in Context

Introduction--Being a physiotherapist since 30 years, I have experienced various changes in the field of neurology and pediatrics. Not only therapists know much more about HOW the brain functions, but we are also witness to change in the frequency of occurrence of various diagnoses. Until the 90s, we treated children with Cerebral palsy, Down syndrome, Spina bifida, etc. clinical presentations that were obvious to the eye.  Rehabilitation terms changed from handicap and disability to later physically challenged, and now to special needs and specially abled. A glaring change is the increasing numbers of conditions such as autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). The signs and symptoms of ASD and ADHD fall along a wide spectrum, not so obvious to the common eye unless quite severe, and can be confusing to parents. 

Therapy – Despite these changes, the ultimate reason for therapeutic intervention is to make the child as functional as possible. It is mostly a bottoms-up approach where, through the right therapy, we influence the development of the brain in the right direction.

Therapists generally assess not only whether the child moves (turns over, crawls, walks, jumps) but also the quality of posture and movement—which reflects neuro motor maturity.

Young parents find themselves in a dilemma when they sense that all is not well with their child while at the same time grandparents or friends advise them to wait and watch. Denial that a child is atypical is a major issue in our fiercely competitive society where we wish only academic success. However, it is crucial to recognize that academic development cannot occur without the foundation of robust sensory & motor systems.

Myths prevalent about children in Indian society—

• Spend a year or more with a larger joint family, and the child will start speaking.
• Put the child in playschool, and he/she will learn to walk.
• Child’s father / mother also walked on toes, and the problem was outgrown.
• All is fine, except that there is no speech. 
• Walking, jumping, climbing…no problem, BUT my child does not sit still. 
• This kid is so smart that he can use an ipad / phone/tablet and teaches himself. 
• Crawling is just a missed milestone, does not matter.

And many more….

Development has to be viewed as an entity of several components such as physical, cognitive, speech and language, emotional, as well as social. Development occurs in all of these areas simultaneously or in parallel, additionally there is an influential effect of one component on another.

A child may rarely have only speech delays, it is highly likely to be accompanied by difficulties in sitting still, engagement in purposeful play, and mingling with other kids. He/she may have other motor issues such as catching /throwing a ball, clumsiness, being unable to hold a pencil, cutting with scissors.

If a child exhibits any of the following symptoms, he/she needs to be evaluated by a qualified clinician.

•         Speech delays, echolalia, poor social skills.

•         Playing with a limited variety of objects.

•         Toe walking.

•         Mouth open.

•         Hand flapping/constantly moving/looking at spinning objects.

•         Poor eye contact.

•         Lack of manipulation with hands.

•         Eating/feeding problems.

•         Serious toileting problems.

•         Sensitivity to loud noises.

•        Attracted to rhythmic sounds such as alarm clock, machines etc.

Movement has to be meaningful which further influences cognition.  A hyperactive child may run around in his /her environment, but rarely sustain or engage adequately in manipulating objects or playing with toys that lead to fine motor abilities and learning.  Goal-oriented movement contributes to strengthening of connections in the developing brain during early school years.

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.

#home chores #functional movement #learning #problem solving 

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