The Humble Staircase

It is a relief to witness the increasing awareness towards health and fitness in the current times. Courtesy to TV advertisements and social media, individuals are at least aware of healthy diet, lifestyle, and the importance of exercise. There is an effort to include movement and exercise via regular walking, Yoga, gym, and many more activities.

On the other hand, we miss out on small but frequent opportunities to exercise our body. In the frenzy of completing endless tasks in a day, we attempt to save time by taking the elevator, parking the car close to our destination, and ordering stuff rather than walking to pick up our food even if it is a nearby eatery. These are valuable short duration exercises that are so crucial for fitness, but ironically lost to us.

For the metropolitan dweller who lives in high-rise buildings, taking the stairs is something that needs to be consciously remembered. In my recent clinical experience, it was a surprise that some children were not used to stair-climbing on a routine basis.

There are many benefits of negotiating stairs—

· Improved leg strength, particularly the knee and hip extensor strength that are among the strongest muscle groups in the body.

· Increases balance.

· Reinforces alternate reciprocal movement patterns of the legs, similar to cycling, thus improving bilateral coordination.

· Enhances cardiopulmonary capacity.

On starting to negotiate 1-2 flights of stairs on a daily basis, I have observed clinical improvements in many children in terms of reduced clumsiness, increased balance, and reduced genu recurvatum (knees pushed back abnormally due to quadriceps weakness).

My advice to parents of young children is to climb 2 flights of stairs twice per day.

To adults, try to climb 2-3 floors before you take the elevator to your apartment on higher floors.

Having grown up in Mumbai during the 70s and 80s, I remember people climbing 4 flights of stairs well into their 50s and 60s. One may argue that they had no option since there were hardly elevators in 4- storey buildings constructed at the time. My perspective is different - they did not give up their daily habit of negotiating stairs. The same habit contributed to their health and fitness.

So why should we give up on climbing stairs at a much earlier age? Remember ‘use it or lose it’? Prior to Covid, it was heartening to hear from an adult that his office staff had decided to avoid using the elevator as much as possible for health and environmental benefits. While working in a New Jersey hospital 30 years ago, we would make it a habit to take stairs rather than an elevator.  

However, no exercise should be overdone. An example would be one of my patients who climbed 16 floors daily in an attempt to lose weight. Within 10 days he developed knee pain and required physiotherapy intervention. Negotiating 2-3 flights, in moderation, if you are not suffering from current injury should be fine. Always check with your doctor or a physiotherapist who is aware of your health conditions of the heart and the joints of your lower body.

So next time you see an elevator anywhere, take the stairs with your child for 1-2 floors. It is good for you, good for your child, and good for the environment. Take advantage of that small but crucial physical activity. Remember ‘use it or lose it’!

Relearning to Cycle

It is believed that one does not forget certain skills such as swimming, driving, and cycling.  This did not apply to me when I decided to start riding a bicycle after a gap of almost 2 decades. Needless to say but important to remember that I am heavier, older, and less agile.  The fear of falling was so profound when I first mounted the new bicycle. On attempting to peddle, I froze with fear when the feet needed to be lifted off the ground. It was difficult to find my footing with the second pedal while one foot was on one of them.  Feeling very much scared, I yelled at my husband when he verbally instructed me in an attempt to help me. The experience reminded of gravitational insecurity that I observe in young children as a clinician.

I felt as if I had no balance since I was perched on a very narrow base of support that a bicycle offers. My eyes were glued to the handle. Steering the handle and balancing on the bike seemed like an unachievable task during the first few rides. I would hold my breath while balancing and consciously remind myself to breathe. It took many rides of practice just to take off, pedal, and keep my balance.

While looking at something far away while cycling, I felt a loss of balance that increased my heartrate. On a quiet street, cycling by a pedestrian or a parked car increased my anxiety (open environment). And making turns was a totally different challenge that took weeks to learn.

Coming up the slope made me realize how decreased were my strength and endurance although I do lead an active lifestyle.  I now cycle on a relatively busy street; but with low confidence, and very well understand that it will take much more practice and effort on my part.

 

So why am I sharing this experience of relearning a skill that I was pretty good at?

Relearning to cycle has been a great experience from an adult perspective, albeit filled with fear and anxiety. It confirms what children experience while balancing and engaging in challenging movement tasks during physical therapy sessions. My personal experience of cycling after many years can be extrapolated to special needs’ children learning to pedal.

Learning the skill of riding a tricycle, and later a bicycle with training wheels is a perennial issue seen in children with special needs.  Cycling requires the following components-

•         ability to sit upright and balance
•        pedal the wheels that needs good strength of the muscles of the leg and the lower trunk
•         the alternate reciprocal movement of the legs requires bilateral coordination between the two legs.
•         maintain the balance while the cycle moves forward (dynamic balance)
•         steering the handle to make turns
•         looking sideways or far away while riding

 All of these components are further challenged when the child graduates to a bicycle with training wheels because the base of support narrows drastically from a tricycle to a bicycle.

Many children receiving physical or occupational therapy, although having achieved the ability to walk, still present with abnormal muscle tone, deficits in balance and vision-perception, gravitational insecurity, and weakness. Most of them have learned to sit and walk at a much later age than typically expected. Therefore, it should follow that higher gross motor skills such as cycling and jumping are going to be delayed. 

Children with special needs should be provided more time and increased practice to learn cycling. Ample patience is warranted from parents and therapists alike.  It helps if learning to pedal is practiced on a stationary bike such as a peddler or a floor bike.

http://sensoryintegrationbangalore.blogspot.com/2016/03/peddler-in-pediatric-therapy.html

Most children at our center have learnt to cycle by practicing on a peddler during therapy sessions. The age range of these children has been 4 years and above, whereas developmentally a child may learn to ride a tricycle much earlier. The time taken to learn cycling has taken anywhere between 1  to 6 months of practice with the peddler. Motor learning of any skill requires repetitive practice of 100s of times.

It is a joy for the parent and a liberation for the child once cycling is learnt. The cycle provides physical exercise, movement, balance, bilateral coordination, and becomes a sensory motor activity. 

·      

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