What is the difference between Occupational Therapy (OT)
& Physiotherapy (PT). This is a question often asked by parents. What is
Physical Therapy?
Physiotherapy is the same as Physical Therapy (used in the
USA).
Although being 2 different areas of rehabilitation, PT and OT
overlap in every rehabilitation setting, more so in pediatric therapy. In the
USA, there is a scope of practice for each of them, delineated by boards,
organizations, and insurance companies. The PT and OT roles vary state wise,
practice wise, and may slightly change periodically.
Having said this, PT & OT are not watertight
compartments. PT is foundational to improving mobility and function; OT is
foundational to functional occupation of the patient. Broadly speaking, PTs
deal with the lower body, gross motor, mobility, transfers, breathing exercises,
and endurance. OTs work on the upper body, fine motor, writing, dressing and
other activities of daily living (ADL). Addressing cognition and feeding overlaps
between OT and speech therapists.
Speaking about the overlap in adult rehabilitation, PT &
OT both work towards improving transfer mobility of patients i.e. transfers out
of bed, transfers from bed to chair, transfers sit to stand, and transfers from
wheelchair to toilet seat. While working in the USA, I have worked on transfers
on a regular basis, either along with an OT, or each of us has done the same
with an aide (based on staff availability).
When it comes to children, there were many tasks that
overlapped between PT and OT. For eg. rolling, sit-stand transfers, sitting and
standing balance tasks would be done by each therapist during different
sessions. Or during a co-session, PT would address postural control, while the
OT would work on fine motor, cognition, visual skills at the same time. If the
PT sat a child / adult on a therapy ball, the OT would work on eye-hand
coordination at the same time.
While in the USA, as a PT, I would still offer a vision-perception
or a fine motor task (e.g assembling a puzzle, fixing pegs on a foam board) during
PT sessions but working on visual skills would not be my stated goal. An OT
would work on vision-perception tasks.
PTs deal with muscle tone, core stability, and postural
deviations that contribute to other areas such as vision, proprioception, and
ultimately learning. The foundations of core strength and endurance that are
addressed through play can contribute to improved handwriting. When we look
closely at children with ASD, a large majority will have issues with muscle tone,
core strength, balance, and endurance.
Scenario in India While nations like USA can afford to have PT & OT both
due to economics and availability of therapists, the situation differs
significantly in India, where there is a shortage of pediatric PTs as well as
OTs. in proportion to the population. India is a vast country, with many small
cities and towns where PT and OT is just starting to grow in the last decade.
Activ Kaarya Parents of young children are referred to Activ Kaarya with
concerns about their child such as motor, sensory, feeding, behaviors, lack of
sitting tolerance, difficulty with coping in the classroom. I am a pediatric PT, with a long experience of
working in the USA alongside OTs. My training in Sensory Integration, as well
as teaching hand and chewing-swallowing biomechanics as a faculty, my practice
comprises a holistic approach of addressing both – motor & sensory
components in therapy sessions. What I cannot do and if the child needs it, I will
refer out to another professional as per ethical practice, eg. Oral Placement
Therapy.
I would like to convey to all therapists in
India, whether you are a PT or an OT, try to look at the child as a ‘whole’
entity. Consider all domains of development - motor, sensory, feeding, communication, cognitive, and socioemotional.
It can be
quite puzzling to parents when their child of 3-4 years demonstrates issues
with communication, behavior, and may have difficulty settling in nursery
school. There are a number of children who have well developed speech and yet
display impulsiveness or lack of attention or anxiety, that become a barrier to
academic learning.
As a
sensory-motor therapist, I have many questions for parents when I first see a
child of 3-4 years, with a diagnosis of autism or yet no diagnosis at all. There
is a certain pattern of responses that I hear from parents; something that conveys
to me that parents need more explanation about what they see in their child. Most
parents report that their child is walking, all milestones were achieved, and all
motor development is fine. But speech is the only concern; there has been
difficulty with attending a nursery school due to atypical behavior.
I urge parents
to think beyond this superficial knowledge of motor development. It is important to know that achieving
milestones or certain positive behaviors is not adequate. Remember that
development is much more than checking off milestones. The list of milestones
should be used only as a reference that the child is developing appropriately.
Just as you need to ‘read between the lines’ in a paper, a parent should
observe the child in subtle ways regarding their eye contact, comprehension,
and feeding. Besides these, a skilled therapist observes many other components
such as quality of movement, how’ are the motor skills accomplished, behavior, and
cognition. In a nutshell, the therapist is assessing the child’s sensory-motor
development.
My child crawled a lot during
childhood. Although the CDC (Center for Disease
Control and Prevention, USA) has removed crawling as a milestone in 2021-22, it
does not mean that we give up on crawling. Crawling can be done as a form of
meaningful activity, even if the child is little older. Experienced therapists
(including myself) see crucial values of crawling such as better reflex
integration, improving core strength, depth perception, cognition, and hand
arch development that impacts their writing in UKG.
My child can do all movements. Does the child squat, bend, or engage in various movements frequently through the day to pick up objects and toys from the floor? Just
because he squats or bends occasionally to retrieve objects from the floor,
doing the same is not finished. Think about your own life as an adult, each of us has learnt to walk
decades ago, but we still need to continue to walk daily, consistently, and on
different surfaces.
The same
with children. If they have learnt one movement, it is not over. They need to
engage in that movement in various ways, many times a day, over months.
Eye contact is good with mother at
home, but not with people outside of home. Since the mother is with the child
all the time in a safe place called home, this is likely. Although eye contact
can be better in the home environment with parents, it cannot decrease drastically when the child steps outside of home. Also, mother is not going to be with the
child forever and everywhere. More importantly, remember that eye contact is a
reflection of the vestibular-visual systems.
My child will eat by herself if
given snack items. She understands everything, she will climb to the kitchen
counter when she wants juice and biscuits. Snack items cannot be counted as ‘real
food’ because they have poor nutritional value and should not be consumed daily
and frequently. As a clinician, I look into whether the child is touching mushy
foods, using fingers or a spoon, bringing them to the mouth, chewing it or just
gulping down. The Indian cuisine abounds in a large variety of foods that are
cooked consistently in every family. Is the child consuming various food
textures? It gives me an outline of their oromotor area functions, in terms of
tactile sensitivity, proprioception, and vestibular system.
Reaching
out for snacks and juice does not mean the child understands everything. She is
only reaching for the food items that she likes. Human babies and children cry
or display a tantrum when they are hungry. They will look for foods that can be
gulped down easily. This is a need for survival.
My child climbs and is not afraid. Is the climbing meaningful? Do they
climb a ladder in the park? Do they engage in stair climbing at home on a daily
basis? If they are climbing on sofas, furniture, or a parents’ lap constantly –
it is not meaningful. It is a proprioceptive seeking behavior, which means that
their proprioceptive system has not been well developed, and they will
demonstrate decreased body awareness, decreased body spatial awareness, and cannot
gauge the force with which they are holding objects.
My child has good balance, never
falls. Not falling is not a sign of good
balance. The child may not be challenging themselves adequately, which is
required for development. Good balance is when they walk on a balance beam,
walk on uneven surfaces, climb various surfaces at home and in the park.
My child does everything, physical
development is very good but doesn’t speak. Although your child is walking and
major milestones may have been achieved, they may still present with low muscle
tone, poorly integrated reflexes, and decreased balance. They may not readily
bend their body or have a good trunk rotation. These are all suggestive of an
immature nervous system.
If the
child is minimally speaking random words or is nonverbal, the best place to
start is sensory-motor therapy. A good program of sensory motor therapy improves
their understanding / comprehension of the relationship between their body and
the world around them. This comprehension is one of the basic steps of
communication.
My child knows the basic colors and
can fix puzzles. Is the child matching colors to a
board, matching in different games (not just 1)? Is the child matching and
orienting puzzle pieces without too much prompting?
Is the child engaging in different
varieties of puzzles?
All of these reflect vision-perception
and fine motor abilities.
My child is very smart because he
can remember car models and nursery rhymes. These may not necessarily be an
indication of high cognition. Remembering and knowing certain things can be accomplished
by rote learning too.
The child
needs to be looked through a ‘whole’ perspective that involves many components
of development.
My child can write 1 to 100, and do
addition on a tab. In my long years of experience, I
have seen many children with autism who are not able to put 10-20 objects from 1
basket to another, although they write numbers. That means that they have
learnt to write 1-100 when it is done consistently but have not understood the
concept of numbers.
Concept
based learning has to develop. Also, fine motor skills of tearing, cutting,
buttoning have to be developed before schoolwork. Ample research shows that
fine motor skills are related to academic learning.
My child knows everything, so can be
enrolled in regular or inclusive school. There is a difference between
knowing and applying in the real-world situation. Moreover, behavior of the
child matters a lot. Sensory and motor issues at home or clinic may seem mostly
resolved. But the issues become magnified if the child is in a noisy and busy
classroom of 25-30 children, and more academic demands are placed on the child.
This leads to behaviors of throwing objects, crying, roaming around, and tantrums
are observed to resurface.
Therefore,
school enrollment has to be well thought over on a case-to-case basis, and
during different time periods. Presence of a shadow teacher helps but may not
always be the case.
Summary
Most
issues with behavior and communication are rooted in sensory processing
differences (SPD). Lack of adequate sensory development leads to poor motor
abilities.
It is important to know what and how
therapists observe / test and analyze the child’s performance in relation to
sensory-motor systems. And what parents need to understand at their end.
A thoughtful discussion based on
parent’s thoughts and reports combined with therapist observations becomes
imperative in knowing the strengths and weaknesses of the child and becomes a
place to start a good therapy program.
#behavior #sensory #motor #development #speech #communication #child development #cognition
The functions performed by our hands are
diverse and complex; ranging from holding and manipulating objects, to kneading
dough, cutting foods, tying, and writing.
Our hand is a manipulator of objects
as well as a communicator. Hand is waved in bye-bye, or thrown up in anger, or
used tenderly to pet a baby. Hand is a functional tool that we use for
pressing, pushing, and pulling. And we use external tools with our hands such
as scissors, hammer, and pestle.
Most children seen at my clinic present with
poor use of hands, sensitive hands, and weakness of hand muscles. These
children have a range of diagnoses, such as autism, developmental delays, slow
learner, and sensory processing difficulties. And there are a number of grade school children who present with difficulties in fine motor skills, handwriting, and attention. Regardless of the diagnosis, I
find that children have a weak grasp of objects, a weak pincer grasp, and
therefore have difficulty with using hands for a variety of functional tasks.
Our finger tips contain the highest density of
touch receptors, that help us appreciate and discriminate various textures,
shapes, temperature, and pressure. Therefore, the tactile / touch input through
the hands and fingers becomes crucial in the process of learning about the
immediate environment in a child’s course of development.
Writing -- As parents of preschool and grade
school children, it is common to have concerns about writing. However, before
holding a pencil and starting to write, a child needs upper body strength,
stability of multiple joints such as shoulder, elbow, wrist, strength of hand
and finger muscles. The hands should engage
in climbing, digging, pinching, pressing, pulling, scrunching, and twisting with
a wide variety of material.
All of these develop through prewriting
activities of using hands in a variety of ways. Besides these, a child will be
ready for letter formation only after they are able to copy prewriting lines
and shapes such as vertical, horizontal, circle, etc. Also visual skills and
cognition are required for writing. Hence, there is immense prep work needed
prior to just giving a pencil and expecting the child to start making letters.
Fine motor skills are accomplished by using
small muscles of the hand and fingers in coordination with the eyes. Young
children need a lot of practice in manipulating objects of various sizes,
shapes, and textures in order to develop finger strength and control.
Following are the videos that demonstrate many
activities that are simple and can be done at home.
Punching on paper – use 2 types of hole
punchers to make holes on paper. The simple punching machine can be used in 2
ways as shown in the video.
Paper tearing --Have your child practice tearing a variety of
paper that you are going to discard. These can range from regular paper to thin
tissue paper to slightly thicker sheets. Your child can tear and crush the
paper pieces.
Translation of small objects and coins within
the palm. This occurs in 2 directions – from fingertips to palm or viceversa. This
activity contributes to arch development and strengthening intrinsic muscles of
the hand that are so important in all fine motor skills.
We have children with special needs where the
primary concern of parents is ‘lack of sitting tolerance’ i.e. the child is
always moving and walking around. Except for the sitting tolerance, the parents
feel that their child is active and there is no problem with moving. As a
sensory-motor therapist, my observation is that the child is moving around the
room aimlessly and without any purpose or meaningful exploration. Most of the
children demonstrate clumsiness of movement. And there is no variation in
movement; either the child walks around or tries to climb short furniture in
the therapy room frequently.
These atypical behaviors of moving around aimlessly
and frequent climbing indicate that their vestibular & proprioceptive
systems are not functioning adequately and optimally.
Movement is a function of our vestibular system. The vestibular system is 1 of the 4 power senses that are foundational to all development.
Why
should we move frequently and variedly?
Humans
were designed to move in space, just like we did so until 3-4 decades ago,
prior to the advent of conveniences in life. In the first 5 years of life,
children engage in active exploration of their surroundings, that leads to
problem-solve and learning. They are required to move their head and body in
various ways so as to provide input to their vestibular system. Variety of
movements include bending down to pick up objects, getting down on all-fours, transitions
between stand and squat, look up to reach and retrieve an object, climb up on
different heights, walk on uneven surfaces, and the list goes on. Movement
should also include effortful work such as push, pull, lift, carry, and drag.
All such movements should be frequently done,
not just on occasion. Let your child carry their own backpack, climb stairs, pull
a small wheelie bag during travels, clear the table after a meal, wipe the
table, make your bed, pull out wet clothes from the washing machine. Such tasks
lead to increased visual-spatial awareness, problem-solving, and learning. These
are skills that the child will need throughout their life; it is work that
boosts self-esteem and self-confidence. When a child learns a new task, although
with some struggle, the process of learning entails ‘figuring it out’ that
consequently leads to neuroplasticity and better cognition as well.
As a course of development, gross motor
movement leads to fine motor abilities. In order for our distal muscles to work,
our proximal larger muscles need to be strong and efficient. If we expect a
child to perform fine motor skills such as cutting, coloring, buttoning, and
writing, they also need to have strength and control of the muscles surrounding
the elbow, shoulder, upper body, and the core muscles. This strength and
control of larger proximal muscles comes from using the body in various ways
other than only walking.
The following video shows some ways in which
opportunities for meaningful movement are provided at Activ Kaarya during
therapy sessions—
It is a little paradoxical that meaningful
movement is needed to improve attention, engagement, and participation in
tasks. Attention cannot develop while
doing table-top tasks. Rather, attention improves when a young child actively
moves through space, explores, and meaningfully interacts with their
environment.
As an adult, think about how good you feel when
you play a game of tennis, or go for a brisk walk, or clean up your room. This
is because you have engaged in movement and exercise that release good
neurochemicals in the brain. If you engage in various movements and exercise frequently
and regularly, you will find yourself sleeping better, and will have more focus
and attention towards your work. The same is for our children. Young children
do need physical exercise in the form of activity and function.
Contemporary
way of life
In our
chase for convenience and the coverup of fast living, we forget to move our
body in ways it should. Many of us rarely climb a ladder, or squat down to the
floor, or sit on the floor even briefly. If adults moved frequently and in
various ways, they become a role model for their child. Eg. climb 1-2 flights
of stairs daily. It is good for you and your child.
In my
clinical experience, I have seen children from grade schools who have anxiety,
difficulty following instructions, struggle with attention in the classroom,
become upset easily, and show aggression frequently. All of these issues are
rooted in their vestibular, proprioceptive, and visual systems not developed
adequately to help them cope up with the external world outside of home. As
soon as we provide them with meaningful movement, effortful work, and
functional visual activities in therapy sessions, their behavior and performance
in classroom improves. My consistent suggestion to all parents has been to
involve your child in age-appropriate house chores – making their own bed, folding
clothes, sweeping and mopping, setting the table. Such tasks boost the child’s
visual-spatial awareness, working memory, sequencing and organization of
actions. More importantly, such chores allow body movement in a variety of ways
that provide input to the vestibular system, that further boosts self-regulation
and behavior.
All
parents need to seriously reflect on ‘how much’ and in ‘what ways’ is your
child moving throughout the day. A child’s
routine involves traveling to school and back, attending 1-2 structured
classes, doing homework, and the day is over. Structures sports and activities
are good, however, they do not provide the cognitive benefits of free play and
unstructured tasks such as house chores. In my experience, children who are
occupied in too many activities after school demonstrate fatigue and
irritability. Therefore, it is wise to
minimize multiple structured activities after school, and replace them with
free play, house chores, and spending quality interactive time with your child.
The integration of sensory and motor components requires a holistic treatment approach where therapeutic activities like prone weight-bearing, trunk rotation, and gait training provide dual benefits by addressing both motor skills and vestibular function simultaneously. Physiotherapists must recognize that movement is crucial for development across multiple domains and should consider sensory integration when treating children with neuromotor impairments, distinguishing between sensory issues that show observable physiological responses and purely behavioral problems.
Parental involvement, particularly from mothers, emerges as a critical success factor in pediatric therapy, helping to build trust and comfort while addressing potential child discomfort due to touch hypersensitivity. Parents need education about therapeutic processes to support their children effectively throughout treatment. Clinicians should watch for specific red flags in conditions like hemiplegia and cerebral palsy, including asymmetrical posture, balance issues, body awareness problems, vestibular and proprioceptive concerns, and tactile defensiveness.
Treatment strategies for sensory processing issues involve gradual exposure to different textures, emphasis on movement therapy, systematic approaches to tactile defensiveness, and holistic methods that combine sensory and motor elements. The fundamental clinical insight is that physiotherapists must understand how sensory processing impacts motor development, as this connection is essential for creating more effective pediatric interventions that address the whole child rather than isolated symptoms -- Dr. KD Mallikarjuna, PT
Ushma ma'am, your emphasis on adding sensory integration gives the exact perspective to paediatric Physiotherapy needed. Humans are sensory beings. So taking into account all their sensory experiences and understanding their implications on therapy was well explained -- Dr. Vidhya Venkatesh, PT
The right hand holds a significant importance in Indian
culture. Not only the right hand, but also the right foot. Giving money to a
vendor or an autodriver, accepting ‘prasad’ at a temple, to making the first
step in a new home are all done with the right side of the body. Some regions
of the country call the right hand as ‘seedha haath’ meaning correct side and
the left hand as the ‘ooltaa haath’ or the wrong side.
Being a physical therapist and having lived in the USA, the
right hand being sacred and the left believed as unholy truly baffles me. The
USA has a much larger number of people who are left dominant. In contrast, in
urban areas of India, the left dominant child catches negative attention and is
perceived as something wrong. My son is left-handed; he writes and eats with
his left hand. During his preschool years, many people asked me to correct his
dominance! But I taught my son to remain cool!!
A 7 years old girl was brought to my clinic due to
behavioral and anger issues. (A diagnosis of autism was doubted by parents and
past professionals at the time). She was also emotionally distraught in that
she would cry without any reason, hit another child, and had poor sitting
tolerance. Careful history revealed that parents were unsure about their
daughter’s dominant hand. The child’s grandmother insisted that she use her
right hand for eating, and hence the parents tried to insist on the same. Besides
the sensory-motor therapy that was indicated for this little girl, my first
priority was to educate parents on not forcing use of a particular hand and to
let the child just ‘be’. In a few weeks, the child started calming down,
following verbal instructions fairly well, and more importantly participating
in fine motor skills and using the left hand for writing. Therefore, I strongly
urge parents to not force your child into using the right hand only.
I have had several children with delayed speech and poor
fine motor abilities, who were forced to hold a crayon and eat their food using
the right hand because the grandmother said so.
Beginning at age 6 -12 months, a child uses 2 hands together and gradually shows preference for either hand around age 3-4 years. Dominance is generally established by 6 years of age.
The other important point for parents to realize that we perform
majority of tasks such as buttoning and tying shoelaces using both hands
together in various ways (bilateral integration). Tasks such as opening or closing a bottle requires
that you hold the bottle with 1 hand (non-dominant) and open or close with the
other hand which is the dominant one. You
hold the paper with non-dominant hand and cut using the dominant one. So the
non-dominant hand becomes the helping hand that provides stability, while the
dominant hand is the working hand that performs the task. As you go through
your day, try to consciously think when and how do you use your hands.
I am trying to emphasize that development of
both hands is crucial as the development of a child progresses from the first
year of life to school years. As parents, offer objects to your young child somewhere
in the center of their space and let them pick it up with any hand. Observe during many occassions as to which hand the child advances to pick up or pull something first. But do not force or insist on using the right hand only.
Do you sit
on the floor at least once a day? Does your child sit on the floor for activities such as art & crafts, or for eating snacks and meals?
Do you sit on the floor multiple times in a
day? How long do you sit on the floor each time? When was the last time you sat on the floor? I
urge all young adults and middle-aged individuals to reflect on these
questions. With older adults, and people with joint issues (hip-knee-ankle-low
back pain), it becomes a different scenario.
Why do I
emphasize sitting on the floor frequently or often through the day? The number
of times you rise from the floor, with or without hand support, has a positive
effect on your heart and lungs. The capacity to engage in physical work in
terms of frequency and duration is known as endurance, and reflects the health
of your cardiopulmonary system. The number of times you get down to the floor and
rise up into standing reflects your endurance.
Multiple benefits of sitting on the floor Sitting on
the floor for work or sitting on lower surfaces that are shorter than regular
chairs provides a different feeling or emotional groundedness. This is
something that cannot be described in words, but is an experience to be
realized.
Better flexibility in all the joints of your lower body is a huge plus in a few days after you periodically get down to the floor and later rise up.
Regular habit of sitting on the floor positively influences your gut health and the digestive system, and provides a deep sensory input to your abdominal cavity.
You will
feel lighter in your body and supple in your general movements.
Benefits of
floor sitting will take you a long way physically and emotionally.
Photo Credit : Freepik.com
Individuals
who have no joint problems and wish to start floor sitting, need to do it
gradually. You can start by sitting on lower surfaces such as a 12” height
stool or a ‘peedah’ or ‘modha’ that are old-style furniture still seen in many
Indian homes. For work, you can put your laptop on the center table or coffee
table.
In my
practice, I see so many children in grade school who either have difficulty
with sitting on the floor or can’t sit on the floor for at least 8-10 minutes.
These difficulties are either due to decreased flexibility of hips & knees
or due to lack of habit (practice) or both.
Myth: Sitting on the floor is not important anymore, we don't need it. In the
contemporary world, we think about anything through the objective lens, trends,
and scientific evidence. We quickly accept or reject something based on a bunch
of papers and numbers. As a physical therapist, I wish to point out the value
of sitting on the floor, it is a topic that is debatable and holds limited scientific
evidence. However, when viewed in a different perspective, sitting on the floor
has been a common practice across all the ancient cultures of the world. In
India, we sit on the floor for all our religious functions. Although the Indian toilet that required
squatting has disappeared from the middle and upper classes, the squat position
is commonly used by laborers, farmers, and domestic helpers.
Look around in
your immediate environment. The
domestic helpers, cooks, and gardeners may be older than you, but are able to get
down to the floor with ease. It is because they do so frequently in their life
throughout the day. This is called ‘practice’ or ‘repetition’ or being used to
it.
So remember to sit on the floor if
you still can, or sit on a pillow or a
cushion, or sit on a lower height of 10-12”. There is nothing wrong in taking hand support of any furniture while getting up. But do not give up on floor sitting while
you are in your 30s and 40s. If you do have pain in any joints, contact a
physiotherapist and take charge of your flexibility. Do not forget the
habit of sitting on the floor.
More importantly, get your children to sit on the floor for many tasks. Make it a habit - frequently throughout their time at home. They can sit on the floor in various ways, but not in W-sitting! Remember that frequently sitting on the floor provides you with a feeling of connection to gravity, to Mother Earth! It is a great feeling that is fast being forgotten.
