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 hyperflexible, 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, and autism 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. Otherwise they are at risk of learning higher functions that involve reaching, manipulation of objects, as well as writing.

Toe walking

Toe-walking is seen in many conditions such as cerebral palsy, muscular dystrophy,  and hemiplegia. In these conditions, it manifests as a consequence of spasticity and/or tightness of the calf muscles. However, toe-walking is also frequently seen in children with autism and sensory processing dysfunction.

There are 3 primary causes of toe-walking:

·         Spasticity and/or tightness of the tendo-achilles (tendon that attaches the calf muscle to the heel).

·         Decreased proprioceptive input through the calf muscles.

·         Idiopathy.

Toe-walking secondary to decreased proprioceptive input through the calf muscles is seen in the presence of hypotonia. In my clinical experience, I have observed a strong correlation between vestibular inefficiency, hypotonic muscle tone, and toe-walking.

Inefficient processing through the vestibular system consequently leads to poor proprioception since there is a close association between the two sensory systems. Toe-walking is a means of gaining proprioceptive input through the calf muscles when there is low muscle tone. 

Many children with sensory processing dysfunction do overcome toe-walking within a few weeks. However, if it persists over months and beyond the age of 03 years, it takes longer and becomes challenging to correct it through intervention. Since the brain adapts to any behavior that persists, toe-walking that persists over years during childhood then becomes a behavioral pattern of gait, i.e. the child becomes decreasingly aware of his/her heels on the floor. Hence  it becomes crucial to take corrective measures as earlier as possible.

Treatment for toe-walking

When spasticity is the underlying cause of toe-walking , the treatment approach is to reduce the spasticity and improve the muscle flexibility through appropriate neuro-developmental techniques, stretching, as well as possible use of braces.

When the underlying causes are decreased vestibular processing and hypotonia , therapeutic activities targeted toward the same become the treatment choice.  Some of these are as follows:

·         Propel the scooter board in sitting.

·         Backward walking.

·         Pushing forward a heavy stroller/ toy cart.

·         Box-skating or walking in shoe boxes.

·         Squatting in a vertically placed barrel.

·         Rubbing foam on heels actively by the child to encourage awareness of the heels.

·         Improving processing through the vestibular system warrants a multitude of activities.

An evaluation by a physiotherapist is essential for identifying the underlying cause of toe-walking, following which the appropriate treatment should be decided.

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Gross motor & Fine motor

In Bangalore, a diagnosis of autism, PDD-NOS, or ADHD translates into occupational therapy (OT) services for sensory integration (SI). There is no denying that sensory integration is mostly practiced by occupational therapists throughout the world. However, many physiotherapists (PT) like myself also choose to train in SI.

In most Western countries, there is a distinct  division of services between  OT and PT. The PT provides services that focus on gross motor activities, address the larger muscles of the body, and mostly the trunk and legs. The OT works on fine motor, smaller muscles of the body, and mostly the trunk and arms. Inevitably, there is an overlap between both services; it is not unusual to see an OT and PT working together to treat a patient and address different goals during the same session.

The concrete reason for my preceding explanation is that fine motor progress cannot be achieved without first addressing the larger muscles of the body that include the trunk. Our trunk forms the foundation for working of the arms and the legs. Weakness of abdominals and/or the back extensors results into an array of problems in posture, postural control, balance, coordination, and fine motor tasks such as writing/cutting/coloring.

We need a good core strength of the trunk  to stay upright, alert, and ready for movement skills such as throwing/catching/kicking a ball. Core strength also plays an important role in climbing playground equipment and keeping balance on uneven terrain. Good postural control is required for all activities ranging from reaching for an object on a shelf to writing efficiently on paper.

Without adequate abdominal muscle strength, speech and respiration are compromised. In my clinical practice, I have observed improved speech, relief of constipation if any, and increase in stamina due to emphasis on improving abdominal  tone and strength.  Activities designed to improve upper body strength result into better writing skills and coordinated use of both arms and hands.

In summary, gross motor precedes fine motor.

#grossmotor #finemotor #physicaltherapy #occupationaltherapy

Mirror Neurons

Mirror neurons are specific  nerve cells in the premotor cortex area of our brain. The mirror neuron system (MNS)  is known as a trimodal system that responds to motor, visual, and auditory stimuli.  These neurons specialize in  imitation learning, action understanding, action recognition, and action execution.  They were first discovered in brains of monkeys and recent research supports their presence in human brains too.

The MNS provides us a way of understanding actions performed by other people around us. It  responds to not only observation of a task, but also to an audio-visual representation of the task. It would fire when you hear the sound of ripping a paper or hammering a nail, and also fire when you read about these actions. The MNS allows children to learn by observation, as well as mapping other s’ actions onto their own actions and language. Therefore the MNS is involved in aspects of learning language, communication, and social skills. Researchers believe that children with autism have  dysfunctional mirror neurons.

Implications of the Mirror neuron system

Throughout  years of clinical experience, it has been my observation that children perform better in therapy when paired with another child.  Some activities such as climbing, jumping, pushing heavy loads etc.are best performed with a partner rather than one-on-one therapy. Mere presence of another child becomes a motivating factor for participation in therapeutic activities.

 My clinical assumption is that the mirror neuron system receives an opportunity for stimulation. However, the activities should be more or less structured and not overwhelm the child.

Children with ASD become socially isolated since they are not able to interact appropriately with peers  and/or they are shuffled between a range of activities.  Just like any other therapy, I would suggest parents to reserve some time for social interaction 1-2 times per week. You can start with inviting a playmate for your child  40-45 minutes at home or in a quiet park. Encourage sharing of toys, taking turns, eating a snack together. Social interaction plays a pivotal role in development of language, communication, imitation and  learning.