With the winter quickly approaching it is time for my favorite Dinosaur PT trademarked activity! The PT Winter Olympics! A great way to involve children in creative and active play incorporating a wide range of gross motor skills!
ICE SKATING/SPEED SKATING
Using colored dots to eliminate friction from floor and colored cones to designate pathway, have child remove socks and speed skate their way to the Gold! You can perform skating sprints or even fun free skating routines.
While not an official Olympic sport, ice fishing is a great way to encourage crossing midline while working on hand eye coordination and trunk control! Find an inexpensive magnetic fishing game and a great bolster or peanut ball and fish your way to victory!
Sliding a bilibo seat across the “ice”towards a target. I use the colored cones to mark the distance traversed. Instead of a curling broom we are all about force generated from a strong bilateral push forward.
Using connecting scooter boards have child lying supine, and using only arms to propel forward.
Again using the connecting scooter boards, now have child in prone using arms to propel forward.
Using tactile discs to represent “mounds of snow”, have child jump side to side either in between discs or over discs. Ski poles are optional accessory!
So with minimal equipment and a whole lot of creativity, have fun training for and competing in the “Winter Olympics”! I think its worthy of the gold!
“W-sitting” is a term used to describe a sitting position in which the child’s bottom is on the floor and their feet are splayed out to the sides from the knee—forming a “W” shape with their legs and knees.
This may seem like a benign position that we see many children utilizing, but it comes with many negative implications. “W-sitting” inhibits exploration, does not allow for proper strengthening of the trunk, and keeps children confined to play only in midline. Effects of long-term “w-sitting” include hamstring tightness and tibial torsion and even hip dislocation. In addition, because this position inhibits trunk rotation it leads to overall decreased balance, trunk strength and postural control.
In a W-sitting position, the hips are placed at the extreme limits of internal rotation, predisposing the child to future orthopedic problems. In this abnormal position, the risk of hip dislocation becomes a concern, especially with a diagnosis of hip dysplasia. Pre-existing orthopedic conditions can worsen when major muscle groups are placed in shortened positions and begin to tighten. These shortened muscles are at risk to form contractures—especially the hamstrings, adductors and Achilles tendon.
Another feature of w-sitting is that it does not engage trunk/postural muscles and encourages poor alignment of the spine. In a w-sit, the child’s thighs roll inward and pelvis tips back to accommodate, causing the spine to form a c-curve rather than it’s natural s-shape.
By changing the sitting position from w-sitting to heel sitting, this child’s feet are pointed straight back, toes down, shins in close to her thighs, which no longer roll inward. This reduces the strain on her ankles, knees and hips allows her pelvis to come up into a neutral position.
W-sitting compromises balance development. A child who frequently W-sits does not need to use his or her trunk muscles. Because W-sitting allows the child to lock into an erect position, the trunk muscles are not challenged and balance reactions are not incorporated. As a result, trunk control and balance are slower to develop and delays due to non-use are common. Frequent W- sitters typically lack stability in their trunk and pelvis and will rely on this sitting position to hold their balance against gravity. It is much easier for children who have not yet developed mature balance reactions to W-sit during play because the hips and trunk are fixed and do not have to do much work. This static positional stability means that the child no longer has to be concerned with holding themselves up. The child does not need to use trunk rotation or side-to-side weight shifting, as the position itself offers the child stability not found in other more developmentally acceptable positions.
Because trunk rotation does not occur during W-sitting, midline orientation is avoided. Children naturally begin to bring their hands together at midline to manipulate objects, but a child who regularly W-sits is discouraged from engaging in this important milestone. Instead, the child tends to use the right hand on the right side of the body and the left hand on the left side, disrupting bilateral hand use and coordination. The W-position discourages the child from crossing over midline, which involves shifting the weight of the upper torso onto the opposite arm and using the trunk muscles to rotate in order to retrieve a toy. Midline crossing, bilateral hand use and coordination are important developmental milestones that pave the way for the development of more advanced motor skills.
What to Do
Prevention is the best method if you catch the problem early. Let the child know about and experience alternative sitting positions. Be consistent. Each time you see the child W-sitting or attempting to do so, correct it. Children often assume this position when transitioning from creeping on hands and knees to sitting on the floor. From all fours, the child simply parts the knees and plops his or her bottom down between them, resulting in the W-position. To prevent this, keep the child’s knees and feet close together when either creeping on hands and knees to sitting on the floor. Assist the child into an appropriate sitting position by gently guiding the legs out in front to promote a “long-sitting” position or using the verbal cue “Criss Cross Applesauce”. Once the child has experienced the alternative positions give them opportunities to participate in engaging play scenarios to gain confidence and comfort in these more appropriate seated postures.
1) Tailor sit aka “criss cross apple sauce” or “Pretzel Pose”
The pretzel pose is truly the opposite of W-sit. It allows for external/lateral rotation of hips and knees, which places these joints in better positioning for proper alignment and development. Tailor sit allows for a great deal of trunk and posture strengthening, due to increased trunk rotation and the ability to cross the “midline” of child’s body. When the child is able to cross midline, we are encouraging the development of bilateral coordination. Bilateral coordination is not only a crucial component of coordination and motor planning, but also essential for the development of most academic, perceptual, and handwriting skills down the road.
Note: child is able to cross midline when sitting in “Pretzel Pose”
2) Butterfly Pose
The butterfly pose is similar to the pretzel pose, but allows child deeper stretch of hip adductors and creates more stable base of support for sitting.
3) Long sit aka “Letter L”
In this position the child sits on bottom, with legs extended straight out in front. This is a wonderful position because it is a great challenge for trunk and posture strengthening. It also allows for increased trunk rotation, which will target the oblique abdominal muscles. The long sitting position can be utilized the encourage hamstring flexibility(which occasionally can become shortened over time for W-sitters).
3) Side sitting aka “Letter Z” - legs bent and tucked to side.
Courtesy of Jewelry Mama
This position allows child to incorporate different stabilization tactics utilizing upper extremity weight bearing and helping with transitions from supine and prone to sitting. If you choose side sit, be sure to alternate sides so that the child will develop trunk control and balance in both directions.
4) Tall Kneel
In this position the child weight bears on bent knees with extended hips and trunk, maintaining an erect upper body. This position maximizes strengthening of the trunk against gravity, with also helps to maximize strengthening at the pelvis and hips joints.
5) Prone position
A great way to stretch hip flexors, encourage upper body weight bearing, shoulder stability/strength, developing proximal to distal control.
6) Sitting on low stool/chair with knees and hips flexed at 90 degrees
Courtesy of Miss Mancy
We want to ensure that feet are flat on floor, knees and hips at 90 degree angle. If using a table/desk it should be about 2” above elbows when arms are bent at child’s side. If table top is too high, child will prop elbows up and out, hike up shoulders and may lean against desk. If table is too low the child will be inclined to round back and lean body on desk.
A child learns through their interaction with the environment. W-sitting inhibits much of that exploration, discouraging integration of balance reactions, sensory input and muscle activation. For a child to truly enjoy their ADVENTURES IN SITTING let’s take the W out of sitting once and for all!
Thank you to MamaOT for this wonderful guest post. MamaOT is a wonderful Pediatric Occupational Therapist who offers really creative and functional activity suggestions accessible to families and therapists alike. I love this post about using the Play Table in 8 different ways following along with the child’s natural developmental sequence. Without further ado I will turn the mike over to MamaOT!
I am so honored that Rebecca asked me to share with you today about baby play tables!
Baby play tables are a great invention. As far as I can tell, they came on to the scene fairly recently (relatively speaking), and I have been amazed at how versatile they are. I’ve used them with infants in early intervention therapy, and they also came in handy for promoting my own son’s development during his first year of life. They have all sorts of cause/effect buttons that sing and light up while introducing baby to songs, shapes, spatial concepts (open/close, up/down), ABCs, and 123s.
Unless someone purchases one for you, don’t bother forking over forty bucks for a brand new baby play table. You should be able to easily find a gently used one on Craigslist or at a second hand store for twenty dollars or less. Just make sure it has removable legs so you can use it in a variety of ways throughout baby’s first year.
Here are eight ways you can use a baby play table:
1. Remove all legs and tilt against a couch, wall, or other stable surface so the play surface is nearly vertical.
Developmental stage: Newborn to rolling (approximately 0-4 months).
Interact with baby and talk to him about the lights, music, and sounds. Help baby lay on his side so he can look at and reach for the play surface. It’s important to get baby on his side while engaging, rather than just laying on his back and reaching over to the side. This is because when baby lays on his side, he is able to engage in “midline play”, which means he is being oriented to where the middle of his body is. Babies are not born with a midline orientation, and it is through midline play that they begin to develop a sense of symmetry (a balance between the right and left sides). If baby will not stay put on his side due to lack of strength or control, simply roll up a receiving blanket and wedge it behind his back. This side-lying position is also helpful for babies who have low muscle tone and find it difficult to engage in midline play while laying on their backs (as they would while playing in a baby gym).
2. Remove all legs and place flat on the ground.
Developmental stage: Tummy time to independent sitting (approximately 2-6 months).
This gives baby some incentive to push up during tummy time. It also gives baby something to play with while sitting up, even if she isn’t so sure about using her hands quite yet. Stay close by your baby on this one. It’s easy for the tummy time baby to suddenly drop her head and bonk her face, and it’s just as easy for the new sitter to quickly topple forward…also bonking her face. If your baby is not yet an independent sitter, that’s okay. Just support her trunk with your hands from behind while she sits and plays. The higher up you support her (closer to her armpits), the less she has to work. The lower down you support (closer to the hips), the more she has to work. Assist her accordingly.
3. Remove only two legs so the table tilts at a 45 degree angle.
Developmental stage: Pushing up and shifting weight during tummy time to pushing up onto all fours (approximately 4 to 8 months).
This is more stable than suggestion number one and, thank goodness, because now baby can reach out and clobber those buttons! The more advanced tummy time baby will find this fun and, again, it gives him an opportunity to engage in midline play no matter where he is around the table. As a therapist, I like this stage because it gives baby an opportunity to practice shifting his weight from side to side while on his tummy. He must shift his weight to one arm while he reaches out with the other. This is an important skill to learn before he can ever think about crawling. The more weight he can bear on one arm while he uses the other to play, the closer he is to crawling! This position also requires quite a bit of trunk and neck strength, which is important for — again — developing the muscles necessary for crawling. And, of course, this position is also fun with the baby who sits independently and is now able to engage more freely with his hands while sitting.
If your baby isn’t really comfortable on his tummy or doesn’t weight shift yet during tummy time, try putting him on his tummy on an exercise ball and slowly zooming him forward to the point where he can reach the play surface. You can help him practice shifting his weight by slowly tilting the ball to the left side (only, like, an inch or two, not a lot) while he reaches with his right. And then tilt it to the right while he reaches with his left. Not comfortable putting your baby on an exercise ball? Check out my post with video about how to play with your baby on an exercise ball. Sometimes a demonstration is all you need to ease your nerves.
4. Remove all legs and place flat on one couch cushion (or an object of similar height).
Developmental stage: Pre-crawling to crawling (approximately 6 to 9 months).
This is a great intro to assuming the hands-and-knees position because it’s easier to sustain a semi-upright quadruped position than it is a fully horizontal one. It takes some of the weight off the arms so baby can venture into a pre-crawling position without needing quite as much upper body and core strength. It also teaches baby about moving up and down through space, as opposed to only moving horizontally all the time (rolling, scooting, etc.).
5. Remove all legs and place flat on two couch cushions (or an object of similar height).
Developmental stage: Crawling to standing with support (approximately 8 to 10 months).
This just about mimics the height the play table will have when you put the legs back on, but it gives baby something to hold onto, lean against, and push against as he transitions to learning how to play in a kneeling and half-kneeling position. Translation: baby’s hand won’t slip off the bottom of the play table and he won’t hit his face on the hard plastic on his way down. We want to avoid injury where we can, right? This is also the perfect height and place for baby to start experimenting with pulling to a stand and remaining in an upright position for more than a few seconds at a time. We’re getting ready for cruising and walking!
6. Stand table up on all 4 legs and have baby use with table wedged into a corner.
Developmental stage: Standing with minimal support to cruising (approximately 9 to 12 months).
You’d be surprised at how much a newly standing baby leans into a play table…and how easily the table can slide or tip with that much weight being put on them. Once my little one reached this stage, I always felt most comfortable if I just wedged the play table into a corner so it couldn’t slide or tip. Of course, a baby this age still needs constant supervision because, as you will soon find out, those chunky little legs are still getting used to supporting all that baby weight and they have a tendency to unexpectedly give out. So stay close to your baby, keep a hand on her, and make sure she’s safe while you engage her with play and talk to her about all the fun stuff going on. Also, don’t be surprised if your baby pulls to a stand, plays for a minute, and then begins to cry…it’s probably because she can’t figure out how to get down! Help her problem solve and, over the course of the next few days or weeks, she’ll soon become a pro at using the table to stand up and squat down.
7. Stand table up on all 4 legs and place in an area where baby can access all four sides independently.
Developmental stage: Standing with minimal support to cruising (approximately 9-12 months).
As baby becomes more comfortable in a standing position, he won’t need to lean against the table so much, so you can get it out of the corner and into the middle of the room! He’ll start to experimenting with taking a step or two to the side, which is the beginning of the “cruising” phase. He’ll also start to become better at pulling to a stand and squatting down to the floor when he’s all done. Don’t be surprised if he starts to become a dare devil and tries to see if he can take both hands off the table. Or better yet, he may become so engrossed in his play time that he will “accidentally” take his hands off without even realizing it…and then quickly put them back on as soon as he realizes what he’s done!
8. Stand table up on all 4 legs and place near another surface so baby can reach over and “walk” to it.
Developmental stage: Cruising to early walking (approximately 10-12+ months).
It may take a while before baby gets up the guts to let go of the table AND step away from it. But oh the look of joy on his face when he does! Create safe opportunities for him to transfer between supportive surfaces, whether it’s a couch, a soft chair, or the very best thing — you! This is the beginning of the walking stage and it — in my opinion — is the best stage of all. Soon your baby will be saying good riddance to that play table in exchange for other, more exciting things to explore. You know, really safe things, like glass coffee tables, fireplaces, toilets, and garbage cans.
Always be sure to supervise and interact with your baby while he or she engages with their baby play table. And have fun!
Working with children of all ages we as Pediatric Physical Therapists always need to keep in mind the fundamental components of alignment, weight-bearing and balance. Here are some tips and tricks to achieve success throughout development!
Visual Cues: Using footprint cut out, colored dots or even therabands to provide visual cue and promote awareness of lower extremity alignment
To promote narrowed base of support…
Using pull tubes for negative space footprints…
Tandem stance for dynamic/static balance…
Colored thera-band for gait training with narrowed base…
To build intrinsic plantar muscle strength and develop arch…
Tactile Cues: using textured surfaces and proprioceptive feedback we can incorporate sensory input with learning of fundamental motor skills
Textured discs provide great sensory feedback…
With supportive shoes to encourage carry over…
Dyna-disc can be used to challenge strength, balance and alignment…
The wobble board with a colored dot can also be used for more of a challenge..
For the future circus performer, a pair of rocker bottom stilts can be a great tool…
We can use the premise of visual and tactile cueing to address step ups…
Transitions and beyond: We can utilize the same components in our motor work, reaching overhead(balloon volleyball), squatting down(puzzle work), crossing midline, bilateral coordination…just adding a weight-bearing component such as a tactile disc, colored dot, foot print cut out help to address balance, alignment, flexibility and weight bearing while we work on other activities. Making therapy fun and productive!
In July 2013, the Journal of Pediatrics published a study entitled, "The Incidence of Positional Plagiocephaly". They investigated 440 healthy full term infants. The incidence of plagiocephaly in infants at 7 to 12 weeks was reported to be 46.6%. Because of this and other recent articles stressing the overwhelming number of children now diagnosed with plagiocephaly, now more than ever I wanted to present a comprehensive picture of the most up to date literature on the effectiveness of plagiocephaly treatment.
I recently began working with an adorable little 7 month old boy. His mother contacted me due to increasing concerns about cranial asymmetry and limited range of motion of head and neck. He is a twin who was positioned under his brother in utero and as a result was born with facial asymmetry and torticollis. He underwent a battery of tests to rule out any possible neurologic causes and was given a “clean bill of health” upon discharge from the hospital. The pediatrician recommended Physical Therapy to gain full range of motion and help to remodel his cranial shape. Mom pursued PT through an Early Intervention agency, but at the evaluation was told that they would not qualify for PT and that mom could simply do stretching at home. She was given a short list of exercises and sent on her way. Fast forward 6 months without PT intervention, this adorable man is still presenting with torticollis and plagiocephaly. In the past month since I began working with him, he has made huge gains in passive and active head/neck range of motion, developing head control in various developmental positions and building endurance in prone position, weight shifting and crossing midline to reach objects and people. While mom is thrilled by this progress, she is still concerned about the residual plagiocephaly. She recently saw a neurologist who without performing anthropometric measurements or any true clinical assessment, explained the only treatment for plagiocephaly is a helmet. He instructed her to have an X-ray, MRI and EEG done and schedule the helmet fitting with an orthotist. Mom was upset by his lack of explanation regarding his rationale, the effectiveness of the helmet and expectations for the future. Let’s investigate this together…
Positional plagiocephaly is a condition characterized by changes in skull shape and symmetry. It typically occurs in infants and results from mechanical factors which, when applied over a period of time in utero, at birth, or postnatally, alter the shape of the skull.(1,2,3) Some infants may have altered skull shape at birth that resolves itself in the early postnatal period. Therefore, positional plagiocephaly refers specifically to infants with changes in skull shape, who are older than six weeks of age. Their cranial sutures are open and appear normal and no craniosynostosis is present.(4)
Typical vs. atypical skull shape
Plagiocephaly ranges in location and severity: from bilateral flattening of the posterior cranium to unilateral occipital flattening and various degrees of ipsilateral forehead bossing.(5) Because of changes in skull shape and symmetry, this disorder causes concern for some parents, as many seek treatment to improve cosmesis and reduce asymmetry. As Bridges and Chambers in a 2002 study explained, "positional plagiocephaly does not appear to be associated with long-term physical or cognitive problems." When treatment is recommended, conservative interventions are advocated, which includes parental education, counterpositioning, Physical Therapy and helmet/orthosis. Counterpositioning as defined by studies by Moss in 1997 and Loveday in 2001, “involves active repositioning of the child during sleep and play, to apply pressure to the prominent areas of the skull and allow flattened areas of the skull to remodel.” Physical Therapy may also include positioning, active and passive range motion of restricted cervical musculature and promotion of variety of developmental positions for play, thereby reducing forces on the flattened areas of the skull. The orthotic helmet is proposed to apply pressure to the asymmetric prominences and provide relief where cranial growth is required.
Example of counterpositioning, here baby is rotated off back at about 45 degree angle to take pressure off flattened spot.
In 2005, the Journal of Developmental Medicine & Child Neurology published a systematic review by Bialocerkowski, Vladusic, and Howell. This review aimed to synthesize current research evidence to determine the effectiveness of conservative interventions for infants with positional plagiocephaly. Sixteen papers met their inclusion criteria. The consistent finding was that "counterpositioning with Physical Therapy or helmet therapy may reduce skull deformity".
Six studies supported the use of counterpositioning with Physical Therapy to reduce skull asymmetries. One study embraced the use of counterpositioning alone to effectively treat infants with mild plagiocephaly. Five studies found benefits of helmet orthotic to reduce skull asymmetries particularly in infants with moderate to severe plagiocephaly. Two studies, one by Moss and one by Jalaluddin, concluded that counterpositioning with Physical Therapy is as effective as helmet therapy. Two other studies by Mulliken and Vles concluded that helmets were more effective than counterpositioning because they ‘correct’ the issue more rapidly than other conservative interventions. I think it is only fair to point out that all five studies, which justified use of helmet orthotic over other treatment methods, had affiliations with orthotic companies, which as we can assume may have biased results.
Once we attempt to compare the studies to one another, we encounter obstacles. In most studies the treating clinician assessed the intervention result using outcome measures without evidence of validity or reliability. Informed consent was not documented in any of the papers. There was no randomization of participants to intervention groups. Also the types of intervention, including duration and frequency were not specified making it difficult to interpret universal approach to interventions recommended. Different outcome measures were used to assess the efficacy of the intervention, again making it difficult to compare study results. On the positive end, the sample sizes were all relatively large and response rates were good. While beneficial, this review left us wanting more investigation into the efficacy of each of the conservative intervention options.
Another study published by the Journal of Pediatrics in 2005 evaluated 176 infants treated with repositioning, 159 treated with helmets, and 37 treated with initial repositioning followed by helmet therapy when treatment failed. They found that infants treated with repositioning at average age of 4.8 months, the mean percentage decrease for the orthotic group was 61% compared to 52% for the repositioning group. A few flaws in this study, the first being the repositioning group length of therapy was 3.5 months while the helmet group was 4.2 months. Each group should have been allotted the same time frame to determine relative benefit of treatment. Also this study only compared “repositioning” to orthotic use. The repositioning was performed by parents who were followed “at monthly intervals to monitor progress and encourage compliance”. The specific protocols are not explained. I would be extremely happy to see a similar study done comparing Physical Therapy intervention(with a defined protocol) to the helmet orthotic intervention. I think that is the missing link here!
This study also evaluated the effect of age on helmet treatment, compared outcomes of 44 children who started treatment at the age of 8 months or older compared to 115 infants who started treatment before 8 months(mean age=5.8 months). In older infants the percentage decrease in cranial diagonal difference was 51% vs 65% in the younger group. Again the flaw is that the treatment length was longer in the younger group(4.4 months vs 3.7 months) and the sample size much smaller in the older group. But in general we can reasonably state, the earlier the intervention is begun the better the outcomes are for children.
Many authors have spent time explaining the potential rationale for the increase in incidence of plagiocephaly as of late. This diagnosis has become more common since the American Academy of Pediatrics’ 1992 “Back to Sleep” campaign, which advises parents to place infants to sleep on their backs in order to prevent Sudden Infant Death Syndrome (SIDS). It is important to note that although the campaign may have indirectly prompted an increase in plagiocephaly cases, it has also caused a significant reduction in the number of babies lost to SIDS.
Many cases of plagiocephaly are linked to torticollis. Proper Physical Therapy treatment for torticollis often resolves the craniofacial asymmetry or plagiocephaly. By removing the muscular restriction causing the child to present with limited range of motion of head/neck and positional preference, the child will more freely change positions and promote redistribution of external forces causing the plagiocephaly. Promotion of tummy time promotes motor skill development, as well as neck/head range of motion, offloading pressures on skull and helping to remodel the head shape.
Promoting tummy time will address head control, increase strength, promote weight bearing, reaching, and reduce external forces causing pressure on skull to decrease asymmetries caused by plagiocephaly
One of the overarching themes in each of the research papers I reviewed is the importance of early diagnosis and intervention.
One study from the 2008 Archives of Pediatric & Adolescent Medicine proposed that identifying positional preference as early as 7 weeks and treating with a 4-month standardized Physical Therapy program “significantly reduced the prevalence of severe deformational plagiocephaly compared with usual care”.
In the case of torticollis as the underlying cause of the plagiocephaly, Cheng et al and Emery et al both state, “If initiated by 3 months, conservative treatment of torticollis with Physical Therapy is very effective, resulting in full passive range of motion and no facial asymmetry.”
Graham et al explains, “After age of 12 months efficacy of orthotic treatment significantly decreases. Delays in initiating corrective treatment until later infancy may lead to incomplete or ineffective correction…so early diagnosis and treatment is essential.”
Since current evidence suggests that positional plagiocephaly is a cosmetic concern more than a medical one, shouldn’t a clinician stress the importance of functional outcomes rather than anatomic? Once the child develops adequate head control, full range of motion, is without physical limitations which may have lead to or were caused by the underlying plagiocephaly, and can get in and out of developmental positions….why are we still concerned? Let’s take a different look at our outcome, instead of head shape let’s spend more time addressing the child’s functional abilities. The helmet orthotic may correct or at least attempt to correct the skull shape, but Physical Therapy strives to address the underlying cause of the plagiocephaly, promotes development and growth free of restrictions and limitations.
The goal of both the clinicians and the families should shift from an anatomic to a functional perspective. Viewing the child as a whole rather than a composite of individual parts can only help to improve outcome.
1. O’Broin ES, Allcutt D, Earley MJ. Posterior plagiocephaly: proactive conservative management. Br J Plast Surg. 1999;52: 18–23.
2.Teichgraeber JF, Seymour-Dempsey K, Baumgartner JE, et al. Molding helmet therapy in the treatment of brachycephaly and plagiocephaly. J Craniofac Surg. 2004;15:118–123.
3. Rekate HL. Occipital plagiocephaly: a critical review of the literature. J Neurosurg. 1997:1–14
4. Fish D, Lima D. Overview of Positional Plagiocephaly and Cranial Remodeling Orthosis. Journal of Prosthetics and Orthotics. 2003; 15:37-47
5. Cheng, J, A. Au. Infantile torticollis: a review of 624 cases. J Pediatr Orthop. 1994. 14:802–808.
6. Bridges S, Chambers T, et al. Plagiocephaly and head binding. Arch Dis Child. 2002. 86(3): 144-145.
7. Moss SD. Nonsurgical, nonorthotic treatment of occipital plagiocephaly: What is the natural history of the misshapen neonatal head? J Neurosurg. 1997 Nov;87(5):667–670.
8. Loveday B, de Chalai T. Active counterpositioning or orthotic device to treat plagiocephaly. J Craniofacial Surgery. 2001: 12(4):308-313.
9. Bialocerkowski, A., Vladusic, S. and Howell, S. Conservative interventions for positional plagiocephaly: a systematic review, Developmental Medicine and Child Neurology. 2005: 8.
10. Moss SD. Nonsurgical, nonorthotic treatment of occipital plagiocephaly: what is the natural history of the misshapen neonatal head? J Neurosurg. 1997 Nov;87(5):667–670.
11. Jalaluddin, M, Moss, S. Occipital Plagiocephaly: The Treatment of choice. J Neurosurg. 2001; 49: 545.
12. Graham et al. Management of Deformational Plagiocephaly. Journal of Pediatrics. 2005; 146(2): 258-262.
13. van Vlimmeren, L et al. Effect of Pediatric Physical Therapy on Deformational Plagiocephaly in Children With Positional Preference: A Randomized Controlled Trial. Arch Pediatr Adolesc Med. 2008;162(8):712-718.
Images courtesy of Perth District Health Unit
As a pediatric physical therapist I am constantly being asked about different pieces of equipment. What is best for children? What will help them develop, achieve gross motor milestones, interact with peers, and so on. We therapists try to keep up with new products on the market, reading up on the literature and, if necessary, trying out the equipment on our own before making recommendations and suggestions.
One such piece of equipment is called the Bumbo Seat.
“Bumbo”, as it is affectionately called, is a one-piece seat that is made entirely of a low density foam. As you can see, it has a deep seat with a high back and sides, plus there are openings for the legs as well a front support and a safety buckle.
The Bumbo Seat is marketed to help babies sit upright.
The Bumbo website states the following: “The Bumbo Floor seat was designed to seat young babies who can’t sit up by themselves yet. As soon as your baby can support their own head you can seat them in the Bumbo Floor Seat. The seat has many technical design features that supports the baby’s posture allowing them to interact with their surroundings. The Bumbo Floor Seat has received many awards from around the world for its effective and functional design but be aware of copy products that lacks some important features.”
As a Pediatric Physical Therapist, I am always mindful of motor milestones, and I use these milestones to guide my treatment and the development of therapeutic goals.
When children are placed in the Bumbo before they are developmentally ready for sitting it can interfere with the natural progression of skills.
Babies rely on different developmental positions to promote activation and control of their various muscle groups, from head control to trunk control to control of the extremities. Children utilize the time first on their back, then on tummy, in sitting, and in standing to gain stability and confidence with their physical being in order to allow them to achieve stability, then mobility, and then gradual independence.
The Bumbo website claims the following: “The floor seat stabilizes the child into slight hip flexion, placing the pelvis in a slight anterior pelvic tilt which facilitates lumbar extension. This action, combined with the gentle curve of the seat back that matches the natural curve of the rib cage, facilitates the baby around the lower ribs and trunk for stabilization.The Seat allows for active practice of the head and postural trunk control. It also allows a child the pelvic stability needed to get the hands into the mid line for play. Upright positioning facilitates an improved visual field of the environment, improved respirations and breath control, assists a baby who needs to be upright after feeding due to reflux and many other benefits.”
If you actually observe a child seated in the Bumbo, there is no active control being achieved. The child is passively placed in position and then locked in. There is no room to build trunk control or pelvic stability because the Bumbo is fixing the child and thus not allowing any muscle activation or joint movement to occur. The child is basically wedged into the deep seat with his or her legs held at a higher angle then the pelvis. There is no natural weightbearing occurring.
The child has both hands and legs free, so they do not receive proprioceptive input to the joints and muscles. Babies rely on developmental positions (such as pushing up on their tummy or sitting while propping themselves with their arms) to allow for weight bearing across the joints, which provides that proprioceptive input. The access to sensory input from the world around us, be it proprioceptive (body awareness through muscles and joints), tactile (sense of touch) or vestibular (sense of movement) helps create the sensory integration babies require in order to make sense of their bodies and the world around them. By positioning babies in an unnatural posture without access to the sensory input they require for development, we are really doing a disservice and interfering with an important and natural progression of development.
Stayathomepapa.com explains his experience with the Bumbo: “Someone lent me a Bumbo to try out. I thought it was a really cool idea. I sat my child in it around 3 months, and I was thinking, ‘This is great. She can sit there while I practice piano or tabla.’ And then I took a closer look. She looked anything but comfortable. The Bumbo seemed to be almost forcefully holding her in an up right sitting position. My wife looked into it, and sure enough she found many sources that suggested this thing was potentially harmful for her posture, and is likely to delay her ability to sit up on her own. That was the last we saw of the Bumbo. You know, if we can just wait until she’s ready to do stuff, our child will develop just fine. Indeed, at about 5 months she was sitting up on her own.”
The Bumbo is a seemingly convenient option for parents, but is it really beneficial to your child? Why do we want our children to be sitting upright before they are ready?How can they interact with the environment around them, people or places if they are locked in one position, strapped into a chair with no stimulation?
Physical development aside, the Bumbo seat has been proven to be unsafe. The first Bumbo seat recall occurred in 2007, of nearly one million Bumbos manufactured from 2003 to 2007, after reports of at least 17 infants falling out of the Bumbo and suffering skull fractures. In August 2012, another recall occurred of nearly 4 million Bumbo seats after reports of 95 babies falling out of the seat and at least 19 infants suffering skull fractures.
A statement from Bumbo itself read, “Bumbo International Trust is conducting a voluntary recall to add a restraint belt and new warnings to the Bumbo Baby Seat. Infants can maneuver out of or fall from the seat, posing a risk of serious injuries. Working closely with the CPSC, Bumbo has determined that the potential safety issue can be readily corrected in the home by adding a restraint belt. In addition, Bumbo is providing a new warning sticker for consumers to attach to the seat to re-emphasize existing warnings against use of the seat on any raised surfaces.”
From examiner.com: “Rather than using a chair, parents looking for developmental benefits should play with their baby and encourage movement”, said physical therapist Colleen Harper, director of developmental, rehabilitative and child life services at Chicago’s La Rabida Children’s Hospital.
“No equipment enhances a child’s motor development; equipment is a ‘baby sitter’ so that a parent can cook dinner, eat dinner or take a shower,” Harper said. “A gross motor skill like sitting is achieved through movement and practice. Children fall out of Bumbo seats because they do not yet have the requisite strength, balance and coordination needed for sitting.”
In a March 2012 Chicago Tribune article, Mary Weck, the clinical coordinator of Physical Therapy at Children’s Memorial Hospital in Chicago addressed the claims Bumbo made in relation to its product:
Bumbo says: “The seat stabilizes the child into slight hip flexion, placing the pelvis in a slight anterior pelvic tilt which facilitates lumbar extension.”
Weck says: “Actually, it does the exact opposite. It puts the baby’s pelvis in a posterior tilt, which facilitates lumbar flexion, not extension. That puts the baby’s chest behind the pelvis. Then the head has to come too far forward. It’s no longer positioned directly above the chest.”
Bumbo says: “The chair allows a child the pelvic stability needed to get the hands into the midline for play.”
Weck says: “Children don’t need a chair to get their hands in that position. At the age they’re using the Bumbo, they are able to do that in a variety of positions anyway.”
Bumbo says: “Upright positioning facilitates an improved visual field of the environment, improved respirations and breath control and assists a baby who needs to be upright after feeding due to reflux.”
Weck says: “Studies show tummy time is good at stabilizing the visual field of the environment. Research also shows respirations and reflux are better when the infant is prone rather than upright, as long as the baby is in the proper prone position. One reason the chairs tip over is that babies need to move. This chair holds them from getting the vestibular motion they need to give them control of their eyes and other sensory issues. All the benefits you get from moving are inhibited in a chair.”
I hope this article once and for all puts the issue to rest. Bumbo is a no-go.
Photo Credit 1: US CPSC, Photo Credit 2: Abigail Batchelder, Photo Credit 3: John Wright, Photo Credit 4: Joe Cheng, Photo Credit 5:Jeff Boulter, Photo Credit 6: Joe Cheng, Photo Credit 7: Dana, Photo Credit 8: Brett Neilson
One of my favorite creations, the make your own Yoga mat! Each of the cut outs represents a different body part. For example, the small blue circles=elbows, the purple oblong heart=the bottom, and so on…
You can use the cut-outs with a single mat, placing velcro on each one to change up the different poses for new and creative challenges. If you need more explanation of materials and construction to build your own Yoga mats feel free to email me at firstname.lastname@example.org!
Shoe recommendations are among the most common question I get from parents and other therapists. This post is dedicated to three typical presentations of gait and lower extremity alignment as well as some shoe options and advice as you venture out into the world of footwear.
Below is an image of one of my clients, with and without proper supportive shoes. Note we do most of our therapy without shoes, to allow for proprioceptive input, promote intrinsic muscle strengthening, address alignment and balance reactions. I advise the use of a good supportive shoe when navigating community and outdoor environment to ensure that in between therapy sessions, children are provided with stability and support as they develop the control on their own.
Before…notice the lack of a medial arch, the calcaneal tilt and line from the lateral to medial malleoli at a sharp angle, also toes are pointed out and though you cannot see, her balance reactions are impaired
After…notice the medial arch promotion, the malleoli at a parallel line and the heel aligned vertically, also promotion of more stable base of support with toes pointed straight ahead
The right shoe or sneaker can provide support and assistance with lower extremity alignment. The right shoe can prevent the need for orthotics later on, can give the child a proper base of support to develop gross motor skills in different environments, can promote proper weight bearing and thus bone mineralization and muscular activation. In case it is not clear, the right shoe is extremely important!
Let’s address a few typical presentations:
1)The child with flat foot(aka low planar arch): These children may have been late ambulators, they may have initially been classified as toe walkers, they may be labeled “hypotonic” by their pediatrician. With the child standing, you will notice the entire foot is contacting the weight bearing surface with an absence of a medial arch. The foot may also turn out, increasing the weight on the inner side and making it appear even more flat. When assessing at this child’s gait, you will notice foot slap, lack of true control as in more typical gait pattern(weight shifting from heels to toes). It is important to note that most children will appear with flat foot until age of 2 or 3. Depending on age at which child began to ambulate this may be even later. No true intervention is necessary if this posture is not otherwise affecting function. Some pediatricians and orthotists will recommend an orthotic, sometimes just a medial insert to support the arch or even an supramalleolar orthosis(SMO) which controls the foot alignment at the level of the malleoli. In my experience a good shoe or sneaker(along with Physical Therapy intervention in the form of exercises/activities to promote proper weight bearing, weight shifting, range of motion and strengthening) can prevent or eliminate the need for an orthotic.
2) The idiopathic toe walker: These children walk up on their toes, but do not have an underlying neurologic or orthopedic condition which causes this. (Here is a past post devoted to the topic: http://dinopt.tumblr.com/post/12072078317/idiopathic-toe-walking) These children may also have been late ambulators, locking their forefoot to provide the stability they need as they began walking. These children may be sensory seekers, craving the extra input provided by the weight bearing force distributed over a smaller area. It is important to rule out an underlying condition which may cause toe walking, for instance check reflexes, assess potential spasticity and range of motion of ankle and subtalar joint. Occasionally if children have been toe walking for a long period of time prior to receiving PT, they may have muscular tightness and range of motion limitations that must be addressed by Physical Therapist and carried over by family at home. These children also may have been recommended an orthotic, sometimes even an ankle-foot orthosis(AFO) which locks the ankle in place and severely limits the child’s natural development of plantar intrinsic musculature and limits the crucial proprioceptive input that children rely on to develop balance reactions and promote proper alignment.
3) The child who in-toes(Also referred to as “pigeon toed”): These children’s feet turn inward when they walk or run, can cause the child to stumble and fall, and results in break down of shoes along top medial edge. The causes of in-toeing can be broken down by where the change in alignment is centered: Metatarsus Adductus(child’s foot curves inward from middle of foot towards toes), Tibial Torsion(child’s lower leg-tibia-turns inward), or Femoral Anteversion(child’s thighbone-femur-turns inward).
Each of the underlying causes of in-toeing may be different, but the effects on gait are similar in the sense that children walk with toes turned inward and may experience loss of balance, due to lack of foot clearance and difficulty maneuvering. These children require help controlling their alignment and base of support to address proper development of muscle strength and activation and inhibition of compensatory strategies that will cause later orthopedic concerns, and potential muscle and joint pain.
While it is easy to get caught up in the details of each particular impairment, the important message is that a good supportive shoe can serve to address postural stability and alignment for the above mentioned conditions. The majority of these children will naturally correct their gait deviations. The structural stability of a good shoe only serves to benefit each child’s progression and development.
Some things to remember when shopping for shoes:
1) Stability(finding a shoe that provides stable base of support, has a bit of weight to it, flexible but durable)
2) Support(a shoe that provides control and support at key places-heel cup, medial arch and forefoot)
3) Comfort(we want the child to feel comfortable, breathable material and shock absorption help to promote comfort and wearability of shoe)
Key terms that will impress your local shoe salesman:
1) Brooks Kids Adrenaline GTS (Youth)
2) Brooks Ghost (Toddler/Youth)
2) ASICS Kids GT-1000 GS
3) New Balance Kids KJ860 (Toddler/Youth)
4) New Balance Kids KJ860v3 (Toddler/Youth)
5) New Balance 760 (Little Kid/Big Kid)
1) Naturino Hiroshi
2) Keen Newport
3) Pediped Sandals-Dakota
4) Pediped Sandals-Flex Amazon
5) Stride Rite-SRT Willow Toddler
6) Stride Rite-M2P Liddle Sneaker
I cannot have a post on sneaker recommendations and not mention some of the worst offenders. Crocs, birkenstocks and flip flops in general! Even if your child is typically developing and does not fall into the above stated categories, these shoe options fail at every test. They lack support, do not provide stable base of support and while they may be comfortable at first they leave children vulnerable to injury due to unwieldy dimensions and/or poor design.
While this post reinforces the importance of good sneakers the recommendations made should be used in conjunction with Physical Therapy interventions to address specific needs of individual children. Shoes can support and promote gross motor development. Please contact me at email@example.com with questions and/or links to specific products mentioned. This list is by no means comprehensive, let me know if there are other products out there that you have had success with! And just to mention I have neither been given these products or received payment in any form by the companies which manufacture these shoes. These are the shoe and sneaker options that I have seen success with in my personal experience with my patient population.
Great post by a wonderful Pediatric OT about making tummy time more fun! Check out her website for more great info(www.mamaot.com)!
I wanted to share a fun idea for therapists and families, roll the dice for a different movement based challenge. You can modify based on your population. I currently have an “animal walk cube”, a “physical challenge cube” and a “ball skill cube” that I use for my clients. You can incorporate it into another turn taking game, as part of a larger obstacle course or it can stand alone as a fun activity. Think “Choose your own adventure” but with PT challenges! I built this one out of a tissue box, scotch tape and some brightly colored paper. Easy and fun!
Pardon my poor stick figure renderings…
Other challenges not pictured here : crab walk to something blue & walk like a giraffe to the door. Get creative and start rolling!
Tips to Promote Standing/Weight Bearing
Recently a friend and my former “buddy” from the NYU DPT program emailed me to ask, "I currently am working with a 13 month old girl who is not weight bearing. We are working on postural strengthening and facilitated standing but she is very unmotivated and would much rather crawl. Any help from an experienced peds PT would be greatly appreciated!!"
I thought it would be a great blog post! So here is the information that I shared with her…
According to the American Pregnancy Association, a child should bear the majority of his/her weight when being held in standing position by 6 months of age, bear weight on legs in supported standing holding on to furniture by 8 months of age, and stand alone by 12 months. Now these are not firm numbers. We all know that there is a range in which development typically occurs. But at this point it is fair to say that without any known underlying etiology this child should be able to bear weight through legs and begin to be motivated by being upright.
First assess any possible underlying neurologic or orthopedic causes. Talk to the family about any red flags that may alert you to a more involved explanation for her lack interest and ability to begin to bear weight through her legs. For instance, a hypoxic episode at birth or history of hip subluxation. When I inquired, my friend mentioned there was no medical diagnosis at the time, she felt that it was a matter of exposure, strength, balance and motivation.
We know how critical trunk strength/stability is to weight bearing so before the weight bearing component I would focus on trunk strength. Using a foam roller to promote quadruped, reaching in four point to shift weight and build oblique and trunk strength, using the peanut ball as a sitting option, the therapy ball to incorporate abdominal exercises.
Once you are ready to address the lower extremity component, start with input to feet, ankle, knee and hip joints
You can use joint compressions, massage or other deep pressure at first, add on other types of input(vibratory, tactile, etc). It can often be a matter of body awareness, bringing attention to the lower leg and the individual joints. We cannot weight bear if we do not trust the strength or control we have over our body.
Once child is beginning to tolerate input through foot and lower extremity, even if it continues to be passively allowing you to place foot on dynamic surface or provide joint compression, then you can add on other challenges.
Using therapy ball or peanut you can facilitate bouncing. With child in standing, place ball or peanut firmly against wall and use your lower body to support ball so that it does not slip. With therapist assist starting at child’s waist, you can increase the input/weight bearing child can tolerate as you move your support from hips to knee joint. Usually incorporating vestibular input is helpful, as it provides a fun sensory experience in the midst of all this “hard work”!
The cube chair can turned on its side for a higher surface to be used for tall kneel, placing desirable to objects on top, from tall kneel child begins to build trunk control and comfort in more erect position. Can help to build into standing activities. Supported standing using stable therapy ball in front for child to have input through upper body, or tall surface with motivating toys(lights and music are always a winner!)
You can use the peanut ball seated on the side to facilitate sit to stand transition, building the fluidity through the lower body and breaking apart the movements of the hip, knee and ankle. Passively bringing the child through the movement by rolling the peanut ball away from you and then allowing the child to take a more active role!
Also encourage the family to take everything at home off the floor, so anything the child wants he or she has to “work” for. All toys and books should be on a surface that requires child to pull to stand or pull to kneel to reach.
If all else fails, sometimes toys such as these provide the motivating factor needed…
Great article from the Annals of Internal Medicine, authored by Dr. Allen Frances, MD, who is a Psychiatrist best known for chairing the Task Force that produced the fourth revision of Diagnostic and Statistical Manual (DSM-IV) and for his critique of the current version, DSM-5. He warns that the expanding boundary of psychiatry is causing a diagnostic inflation that is swallowing up normality and that the over-treatment of the ‘worried well’ is distracting attention from the core mission of treating the more severely ill.
Frances’s writings were joined by a general criticism of the DSM-5 revision, ultimately resulting in a petition calling for outside review signed by 14,000 and sponsored by 56 mental health organizations. In the course of almost three years of blogging, Frances became a voice for more than just the specifics of the DSM-5 Diagnostic Manual. He spoke out against the overuse of psychiatric medications—particularly in children; a general trend towards global diagnostic inflation—pathologizing normality; the intrusion of the pharmaceutical industry into psychiatric practice; and a premature attempt to move psychiatry to an exclusively biological paradigm without scientific justification. Along the way, he wrote two books: “Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life” and “Essentials of Psychiatric Diagnosis”.
I wanted to take a quick break from all things Pediatric Physical Therapy to wish the most beautiful French Bulldog, Daisy Duke, a very happy birthday! Today Daisy(also known as Daze of Thunder, Baby D, Grumpster #9) turns 10! For those of you who do not know, five and a half years ago my husband(then my boyfriend) and I decided we wanted to adopt a dog. We had fallen in love with a particularly adorable skateboard riding French Bulldog in our neighborhood and thought that a Frenchie might be the perfect fit. We searched the web for rescue networks and found the amazing FBRN(French Bulldog Rescue network). Being as my husband and I were both getting our doctoral degrees in Physical Therapy at the time, we thought it would only be fitting to adopt a dog with special needs. Once we happened upon this adorable face how could we resist!
Daisy as a puppy
At age 3, Daisy’s prior owners noticed progressive weakness in her lower limbs and loss of bladder function. They opted for a surgical procedure to fuse her spinal column. The doctors informed them that the chances of Daisy regaining full function were low. Daisy was effectively paralyzed from the waist down after undergoing the surgery. When her owners were told by the vet that she this was now in fact a permanent condition, they decided that they would like to “put her to sleep”. Luckily the vet, realizing that Daisy was both a healthy and happy pup, who with the right support would be able to adapt to a life with lower limb paralysis, decided to contact FBRN and see if they had a family who would like to adopt her. And boy did they…
In November of 2007 Rory and I drove to a small town in upstate New York where Daisy had been temporarily living with a foster family. We spent the day with her eccentric but caring foster mom, who taught us the ins and outs of caring for a dog with spinal cord injury, using her lower limb wheelchair, expressing her bowel and bladder, diet and exercise routine. Finally after what seemed like an eternity, we were able to take our snorting princess in our arms and bring her home. She loudly voiced her glee with guttural grunts the whole way home(one of the many joys of the brachycephalic breed) and was completely exhausted by the time we reached Brooklyn and showed her to her new home. From the first minute we saw her big brown eyes in the photos to the day we brought her home, to today as we celebrate her 10th birthday and our 5 1/2 year anniversary as a family. She has been the most amazing addition to our lives. She kept me company(and my bed warm) while Rory attended medical school in Israel, she is the most vociferous New York Giants fan, she wheeled down the sandy aisle as the flower girl at our wedding two years ago, she is the mascot for Dinosaur PT and she inspires all those around her to look obstacles in the face and overcome challenges head on. She continues to be happy and healthy and gorgeous as ever, and we look forward to many more birthdays together. Happy Birthday Daisy Duke!