Rolling

Rolling

A typical question for most physiotherapists who see children (and honestly one I think most moms ask themselves at one point or another) is ‘should my child be doing X by now?’  So, I thought I would take a few blog posts and write a little about each of the big gross motor milestones.

Let’s start with rolling, the same thing most kiddos will start with.  I know for my husband, that was when ours stopped being “a loaf of bread” and became a tiny human to him – suddenly they can move!

What does it take to roll?

Rolling can seem simple to us as adults but in reality is quite complex.  There are a LOT of components to rolling.  A child needs neck control, shoulder mobility and control, the beginning of core stability and, finally, hip and knee control.  Without all of these components, the child may not be able to initiate the movement, or they won’t be able to control the momentum.

To start learning all of those fundamental building blocks (especially the neck control and shoulder mobility/control), it takes practice, and that means TUMMY TIME!  Tummy time is so vital – more on this another day!

The start of rolling

The first part of rolling that parents typically see is when their child is on their back and they are able to roll to their side.  This usually starts to emerge around 2-3 months.  This either happens because they are looking at something to the side and up from them or because they put their feet in the air and they tipped over.

Then it progresses to a purposeful head movement and the body follows the head. When this starts, the body is quite stiff and tends to roll like a log, and the roll can be a bit uncontrolled sometimes, startling a baby.  But, as those fundamental skills improve with practice, we see rolling with rotation and bending through the trunk.

To roll from tummy to back, babies need to bring one knee up toward their chest and lift their pelvis slightly to start the roll.

When should my child roll?

Some children start rolling as early as 4 months, but a typically developing child should roll both directions by 6 months.

If your child is not showing the building blocks to rolling by 4 months or isn’t rolling by 6 months call your local pediatric physiotherapist!  As always, if you are in Kitchener-Waterloo or Perth County, give me a shout!

Private AND Public Therapy Services?

Private AND Public Therapy Services?

This is a big topic amongst a lot of my families and within the therapy community in general.  It’s a conversation I would say I have at least twice a month with a family, another physiotherapist or another therapist from a different discipline:

Can I use private therapy services even if I’m getting treatment through the public system?  Why would I see a private therapist if I’m being seen in the public setting?  Should I see one vs the other?

My answer is: do BOTH!

I encourage all of my families to call their local children’s treatment centre (in our area, you can get in touch with either KidsAbility or Thames Valley Children’s Treatment Centre) and put in a referral for services.  Parents can self-refer or a medical doctor/specialist can refer on behalf of a family.  This is a vital resource that can help get access to a variety of services, including therapy and, in the long term, planning transition to school.

The most important thing is to get the referral in early!  Some treatment centres only provide services until school age, at which time care is transferred into the school system.  As well, given the number of children requiring services, wait times for assessment and treatment can be lengthy.  The sooner you put in your referral, the better!

So, what is the role of the private therapist?

Treatment in the public system looks different for different families.  For some families it’s more consultation based – once every month, or six weeks to provide suggestions for exercises at home, providing equipment to increase a child’s function or ease of caregiving.  For other families, it may be blocks of treatment 2-3 times a year to work on specific goals.

This is where a private therapist comes in!  I have a number of families I have seen while they are waiting for public services and, in some instances, we are able to achieve their goals before they get their assessment.  For other families, a private therapist can provide more frequent, hands on treatment to supplement public services they may be receiving.

However, there are some guidelines we need to follow – the College of Physiotherapists of Ontario has a standard of care that lays out the expectations for a physiotherapist who is treating a client who is receiving care from another health care provider (including a physiotherapist).  The key is communication between the client/family and the other treating therapist.  We need to make sure the treatments are compatible, discuss how the therapists are dividing treatment and that there is nothing that interferes with the delivery of safe, quality care.

At the end of the day, I feel like the more help a child can get to accomplish their maximum potential, the better!  If a family can afford private physiotherapy (through benefits, bursaries or private pay) I think it can be a wonderful addition to public services.

The Truth About Toe Walking

The Truth About Toe Walking

Let’s talk about toe walking!  I recently went to a course solely focused on toe walking and was super excited to go.

Why?

Because I had been finding that these kiddos were hard to treat, I often wasn’t getting the gains I had been hoping to, and, when I did, they didn’t always last.

Let me tell you, this course changed EVERYTHING!

I will honestly admit I had been doing it wrong all along!  I had been taught in school (like most physios) that toe walking was the result of tight calf muscles.  So, we did things like stretches, night splints and surgery.  What we now know is that tight calves is the consequence, rather than the cause.

Idiopathic Toe Walking

It isn’t uncommon for children who toe walk to be diagnosed with idiopathic toe walking.  Idiopathic means that there was no known cause, but what has happened over the years is that is has morphed to people thinking there isn’t a cause.

NOT TRUE!

There is always a cause.

Toe walking is super inefficient, and the only reason your body will do it is to meet a greater need.

Toe walkers of today are different then the toe walkers of previous generations.  We are using more equipment with our kids than we used to and more supportive toys when learning to walk.  We have more kids with sensory needs and/or autism.  All of these things make for fundamentally different toe walkers.

Which means that the assessment and treatment of these kids needs to go beyond looking at the calves!

Wait and See

I have come across some families that tell me they were informed that toe walking is normal and not to worry, as they will grow out of it.  Toe walking is NOT a normal part of development – if your child has just learned to walk in the last week or two and you see them up on their toes and then they go back down to the soles of their feet, and this happens less and less, then you likely don’t need to be concerned.  But studies show almost all 18 month olds step with their heel first.

Did you know our balance strategies during walking are developed by 3 years old and the bones in our foot are solidified by 4 years old?

AND it is possible for walking on the toes to actually deform the foot bones!

It’s a challenge to make changes to both of these things after that point.

Lastly, our adult walking pattern is solidified by 7 years old, so how a kiddo walks at 7, is how they will walk as an adult.

That’s why earlier is better to try to address these issues BEFORE our foot, balance and walk are all solidified!

Toe Walking as a Marker

Earlier in this post I talked about how toe walking is inefficient and that the only reason someone will do it is to meet a greater need.  A new study has shown that there’s a correlation between speech difficulties, learning disabilities and toe walking.  This likely explains the underlying reason the child is toe walking in the first place.  Because children typically start walking before they have much speech, toe walking can be a marker for other concerns that haven’t yet emerged, but should be monitored.

Long Term Consequences 

You may be thinking, what is the big deal?  Is it THAT important that my kiddo is up on their toes – they are walking, right?!

Wrong!

There are long term consequences!

Some long term consequences of toe walking include increased frequency of injuries, knee instability, difficulty finding shoes and early arthritis and joint pain.

But what about those kids that can, when asked, put their heels down?  A recent study found their calf strength and overall endurance was significantly less then their peers, which means they have a harder time keeping up!

There is an interesting video/interview here talking about the long term repercussions of toe walking.

So, the long and short of it is that toe walking is a complex issue, much more than most physiotherapist and doctors ever thought.  Treating it is possible without drastic measure such as night splints, botox or surgery.  However, as with most things, the earlier the issue is addressed, the better the likelihood of results.  So, if you have concerns regarding your child’s toe walking, book an appointment with a physiotherapist who has training in toe walking and will take a wider approach than  simply looking at their calves!  If you are in my area feel free to reach out to me at erin@newhorizonsrehab.com or (519) 291-5402.

Plagiocephaly – The Flat Head Trend

Plagiocephaly – The Flat Head Trend

Okay ,so maybe trend is the wrong word…trend to me implies something cool or something we want, plagiocephaly or flat head syndrome, however, not so much.

What is plagiocephaly?

Plagiocephaly is the asymmetrical flattening of the head, either at birth or just after birth.  Typically it is a flat spot on one side of the back of the head, with forehead, ear and face changes in severe cases (looking like a parallelogram from the top).  Less often, it is a flat spot at the centre back of the head, called brachycephaly, which causes a widening of the head and can elongate the top of the back of the skull.

Plagiocephaly can occur with or without torticollis. Congenital musclular torticollis, as it is called in infants, is a shortening of the sternocleidomastoid muscle in the neck, which results in the head being tilted and rotated to the side, leading to a flat spot on the back of the head. When there is no torticollis present, it is called positional plagiocephaly since it is as a result of positioning.

Whew…that is a lot of medical terms, let’s move on!

Research has uncovered some predisposing factors both during the gestation period and after birth. During the gestation period, obviously, the less space a baby has, the higher the odds are that a positional deformity can start.  Males, multiples, babies with large gestational size, first borns and breech position are all risk factors.  Once the baby is born, factors increasing the risk include limited tummy time, lower activity level, exclusive bottle feeding and sleeping on the back.

BUT wait!!!!  Aren’t babies supposed to sleep on their backs?!

YES!  But this is the same reason plagiocephaly is on the rise.  Over the last 24 years, since the Safe to Sleep initiative started (formerly Back to Sleep), in an effort to decrease Sudden Infant Death Syndrome, plagiocephaly has seen a dramatic rise.  Studies, the most recent from 2013, are now placing the incidence of plagiocephaly at approximately 48% of 7 week – 4 month olds.  I would argue that it has probably increased again over the last 5 years with the increase of container babies. (You may be reading that and thinking WHAT?!? Stay tuned to a future article about container babies!)

What can we do about it?

There are a variety of things you can do to help prevent and improve plagiocephaly, including positioning suggestions, tummy time and using a Mimos Pillow.  In severe cases a helmet therapy may be recommended.

The Mimos pillow is a pillow that is designed to spread out the amount of contact the head has on the pillow. This means that rather than have one condensed area of pressure it distributes it which can help prevent plagiocephaly.  If the flat spot is already present, the use of the pillow, in conjuction with physiotherapy, can help correct the head shape.  It is a class 1 medical device (meaning is safe to use), so no need to worry.  Check out Mimos Pillow for further information.

Why wait and see isn’t a good plan

I occasionally hear parents say they got told to wait and see and that it will improve – in very mild cases that may happen.  However, timeliness can be important!  Typically, we see the most change within the first 6 months after birth and, should helmet therapy be needed, you want to get started ASAP.  Once the skull fuses, there is little change to the shape.

If your child is one of the many that has plagiocephaly, I encourage you to reach out to your pediatric physiotherapist to assess for torticollis, take measurements to monitor the progress, give you positioning suggestions and measure you for a Mimos pillow (they sometimes even have discount codes available)!

Should you have any further questions feel free to contact me!

Sitting Still in School

Sitting Still in School

I came across this article recently and, although it’s a bit older, it got me thinking.  I too, like Angela Hanscom, an occupational therapist, have parents who have been getting feedback from their children’s teachers that they are concerned with ADHD and fidgeting in school.  I often get questions from parents on how long their child should be able to sit for during class.  And, vice versa, teachers who feel that children aren’t able to sit, pay attention, and participate appropriately.

In the article, Angela discusses observing a typical classroom (not special needs) at the end of the day and seeing that kids were tilting back in their chairs, fidgeting, chewing on pencils, etc.  From what I hear from my friends who are teachers, (a variety of elementary grade levels) this is pretty typical.  When I hear this, I can’t help but think that I don’t really remember that from when I was a kid in school.  Sure, there was the occasional kiddo who would play with a pencil, or lean back in their chair on the occasional day, but not the majority of the class on a daily basis.  So what happened?!?  Why is this happening?!

Angela touches on two things in her article, the first being our expectations for kids to sit for longer periods.  I know this will fluctuate from school to school and teacher to teacher, depending on how their classroom is structured.   However, the constraints of getting everything in that needs to be taught, as well as school policies, often means that kids are sitting for looonnng periods of time.

I was speaking to my family on the weekend and got asking my niece a bit about this.  In her school, the children don’t move class to class for different subjects (which we did as kids – at least specialty ones), they stay at their desks and the teachers come to them.

The second is that our kids are just not moving enough! From an occupational therapy perspective, she talks about how not having kids move is effecting their attention.  And I whole heartedly agree!!  But what really got me thinking, is how this all relates to the kids I see here in physio.

I have been seeing more and more kids in the last little while whose parents tell me that their teachers are concerned that they fidget constantly.  When I assess them, the trend tha I’m seeing more often than not is that they don’t have much core strength (*Check out my past blog posts to learn more about our core).  So, I have been paying close attention in sessions, as well as when I get them to come in from the waiting room, and I’m starting to think these kiddos fidget as a strategy to compensate for their lack of core strength. (Hence why this article seemed perfectly timed in a connect the dots kind of way!)  I would have typically described kids with poor core strength as those kids who melt into chairs and lay on their desks (and I do still hear about quite a few of those kids as well), however I like to think of these kids as a new breed of poor core strength kids.  These are the kiddos who parents might think are strong (“They have a six pack, how can they have a weak core?”), however, when you test them they have okay initial strength, but their endurance is not where it should be.  Again this goes back to kids not getting enough time being active – a sport two days a week for 45 mins is just not enough time!  So, instead of melting, they move constantly to recruit different muscles and to give those tired muscles a break.

I also keep thinking that the types of moving kids are doing now is also different to what we used to do as children, and that the issue is starting long before these kids get to school.  But this post is lengthy enough (these next two thoughts I could chat for hours about lol) and I don’t want us all sitting reading and not MOVING, so look forward to future blog posts on container babies (WHAT?! …just wait!) and why risky (and rough and tumble) play is important!

Core Strength in Kids

Core Strength in Kids

We have all heard the buzzword ‘core strength’ being thrown around with respect to health and fitness in adults, and know we should all be working on it. But, what most of us don’t think about is how important core strength is for children and their development. Let’s start at the beginning…

What is the ‘core’?

There is actually an inner core and an outer core set of muscles and they need to work together.  Our inner core is made up of the transversus abdominus, the pelvic floor, the respiratory diaphragm and the multifidus. These four muscles work together deep in the body to stabilize our spine and pelvis.  Our outer core includes the rectus abdominus, the erector spinae, the external obliques and the muscles that stabilize the shoulder blades and hips.  These are the larger muscles that do more of the moving.  The key is for both the inner and outer cores to work in harmony with each other.

Why is core important?

The core muscles primary role is to provide balance and stability – this is no different in children and is, in fact, more important than in adults, as it is the foundation of all skills.

Children should be developing strength from the inside, aka core, outwards to the arms and legs.  This starts with posture/alignment.  Children with weak cores often look like they are melting when sitting on the floor or in a chair, or will use compensation strategies such as W-sitting to keep more stable.  Without this foundation, children can have difficulty with balance, and the more complex gross motor functions such as running, jumping or even playing soccer.  Less often thought of consequences can include difficulty with fine motor tasks such as writing and speech concerns.

How do those relate, you ask?  With fine motor tasks it is important to have a solid trunk and shoulder control, ie. core strength, which then allows easier hand manipulation and more control.  Speech can be affected by a weak core, as one of the four inner core muscles is the respiratory diaphragm which controls our breathing.  Without a properly functioning inner core, controlling and timing our breathing becomes difficult, which then affects how we speak.  Amazing how important our core control is in so many different ways.

How do we work on core strength?

Of course, most of us know the traditional ab exercises, however, these are not the best way to work on both the inner and outer core muscles.  On top of that, for us to engage these muscles properly, we need be in good alignment.  In children it can be an even bigger challenge as, of course, they don’t want to do exercises and so it needs to be fun!

It’s important if you suspect your child has a weak core to see your paediatric physiotherapist to ensure your kiddo has ideal alignment and to work on increasing their core strength.

Shoes, Shoes, Shoes!!

Shoes, Shoes, Shoes!!

Let’s talk shoes!  I will admit, I’m a shoe girl, even the ones I know aren’t good for me.  BUT when it comes to my daughter’s footwear, I’m pretty strict with what I put her in.  Why?  Because her foot is still developing, the foot that will support her for the rest of her life.

When we are born, our bones are soft and malleable, and over the first two years of life the bones harden, until we have a firm foot.  But wait!  My kiddo is older than 2 and I’m still fussy about what shoes she wears…why?  Our foot, and gait (walking pattern) continues to develop up until 7 years of age when we have our adult gait pattern.  So, she has a few years yet before I will stop being picky about her shoes.

So, what do I put her in?

First let me say that the recommendations that will follow are for typical children (no neurological, sensory or developmental diagnosis) with NO foot or gait abnormalities.  *Look for future blog posts talking about atypical kiddos and abnormal gait patterns such as toe walking.

When we think that about our foot changing and maturing through until 7 years old, obviously our development and what we are doing is quite different throughout those years.  Therefore, our shoe recommendations change depending on what stage we are in.

Pre-walkers, ie babies and crawlers, do not need shoes.  They need booties or pre-walking shoes that do not bind their feet.  The shoe should be flexible rather than providing a rigid support, and it’s very important that the shoe be shaped like the child’s foot.  The function of a shoe at this age is warmth and protection

Toddlers, who tend to use a lot of energy walking, should have a lightweight flexible shoe. A leather or canvas tie shoe is more secure, will stay on the foot, and will fit fat little feet better.  I think this is a bit of change from what kiddos have worn in the past.  I know my first shoes were very stiff, firm leather high tops and I have had lots of comments from the older generations about not putting my child in “supportive” aka stiff shoes.  When we are learning to walk, we learn a lot from feeling the floor under our feet, so flexible is key!  Toddlers should have flat heels on any shoes and they ideally should go barefoot in a protected environment such as indoors.  I know this isn’t always possible – my daughter goes to a daycare where they are required to wear indoor “shoes”.  So she is that kiddo who is still wearing leather Robeez inside all day.

For school aged kiddos, style and shoe fit is important with the main function being shock absorption and protection.  At this age, they can choose from a variety of options, including athletic shoes, sandals, hiking shoes, etc.  It is very important to wear the right shoes for the right activity to prevent injury.  Look for reasonably priced, flexible, well-ventilated shoes that allow plenty of room for growth.

The American Academy of Pediatrics has some overarching recommendations on what to look for when buying shoes.  Shoes should be lightweight and flexible to support natural foot movement with a stable base; they should be made of leather or mesh to allow the foot to breathe and they should have good shock absorption with durable soles as children get into higher impact activities.  They shouldn’t be stiff or compressive, as this may cause deformity, weakness and loss of mobility. In general, base your shoe selection for children (*typical children) on the barefoot model.

I do get questions on what specific brands I recommend.  I honestly think it depends on the stage of development and what fits your child.  Robeez and Momobaby are great for infants and toddlers.  Pediped; Stride Rite; Keen; ASICS; New Balance and Saucony all have some great options for children.

If you have any concerns about your childs foot or walking pattern I urge you to speak to your paediatric physiotherapist as soon as possible. We want to ensure your child has the best foundation (their feet!) to support the rest of their development.