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night splints

The Quick Guide to Night Splints for Children

 

 

 

For many children who are idiopathic toe-walkers, physical therapists often take the conservative approach. We have many things in our arsenal to help children improve without undergoing costly and painful surgery. Outside of stretching and strengthening exercises, we might recommend ankle foot orthoses (AFOs) for day time and/or night time wear. Depending on the child’s range of motion measurements, walking mechanics, and underlying pathology, different types of orthotics might be recommended. We often work closely with orthotists (professionals who design medical supportive devices such as braces) to make sure each child receives the individualized care and equipment he needs to gain full function and optimal alignment.

Here are reasons why your physical therapist might have recommended night splints for your child:

  1. The main goals of physical therapy interventions for toe-walkers are to increase ankle dorsiflexion range of motion and to decrease possible contractures that are associated with the condition. Physical therapy exercise programs include stretching the calf muscles, strengthening the trunk muscles, manual therapy, treadmill training, balance training, and ankle mobility training. Sometimes, in stubborn cases of toe-walking, orthotics are needed to maintain the range of motion gained throughout daily exercise sessions.
  2.  If you’ve ever tried to stretch your pre-schooler’s muscles, you know that children can be active and fidgety. They don’t tolerate passive stretches as well as adults and might complain of boredom, pain, or ticklishness. The most effective stretches are those held for a prolonged period of time at a joint’s end range. Night splints allow for increased stretch time at the ankle joint, because the child is sleeping or resting when they are in place.
  3. The best time to gain range is when a child is relaxed. Since children relax more during sleep, even more range can be gained through passive stretching using a night time AFO.
  4. This is where the night-time splint comes in. While the daytime AFO is a rigid orthosis that keeps your child’s ankles from plantarflexing (pointing down) past neutral while he walks, the night time AFO is a much more dynamic system. Night splints can be adjusted as the ankles gain more range into dorsiflexion. They provide a low-load, prolonged-duration stretch that helps with contracture reduction and counters high tone.
  5. In the literature, night splints have been found to be effective for contractures at a variety of joints, and can be useful in brachial plexus injuries, cerebral palsy, and muscular dystrophy.

As pediatric physical therapists, we rarely recommend over-the-counter orthotics for your child’s orthopedic needs. By consulting with an orthotist, we make sure each child is fitted to the most comfortable and developmentally appropriate custom foot wear for his condition. Usually, children who adhere to a strict physical therapy program and who receive the right orthoses can see a complete change to their posture and gait mechanics in as short as 6 months’ time.

Click here to view our gross motor milestones infographic!

References:
Cincinnati Children’s Hospital Medical Center. Evidence-based care guideline for management of idiopathic toe walking in children and young adults ages 2 through 21 years. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2011 Feb 15. 17 p. [49 references]

Laughing baby with ball

Understanding Physical Therapy Outcome Measurements: The Peabody Developmental Motor Scale, Second Edition (PDMS-II)

 

 

 

In my previous blog about the Alberta Infant Motor Scale, I mentioned that as a baby ages, more age-appropriate developmental motor scales must be used to monitor achievement of skills.  The Peabody Developmental Motor Scale is a comprehensive and reliable tool used to measure both fine and gross motor activities early in life. It was designed to assess motor skills in children from birth to 5 years old.  A majority of physical therapists use this assessment to monitor toddler and preschooler development.

Laughing baby with ballThe PDMS-2 is not just limited to physical therapist use. It can be helpful to occupational therapists, diagnosticians, early intervention specialists, adapted physical education teachers, psychologists, and developmental pediatricians who are monitoring motor abilities of children younger than five.  The six subtests that make up the PDMS-2 can be used separately or can be combined to collectively describe a child’s gross motor skills (Gross Motor Quotient), fine motor skills (Fine Motor Quotient), or overall motor skills (Total Motor Quotient).

See below for a description of each subtest:

Reflexes: The 8-item Reflexes subtest measures aspects of a child’s ability to automatically react to environmental events.  Because reflexes typically become integrated and less obvious by the time a child is 12 months old, this subtest is given only to children from birth through 11 months of age.

Stationary:  The 30-item Stationary subtest measures a child’s ability to control his body within its center of gravity and retain equilibrium. Stationary skills include standing on one leg without falling, or standing on tiptoes.

Locomotion: The 89-item Locomotion subtest measures a child’s ability to move from one place to another.  The actions measured include crawling, walking, running, hopping, and jumping forward.

Object Manipulation: The 24-item Object Manipulation subtest measures a child’s ability to manipulate balls.  Examples of the actions measured include catching, throwing, and kicking.

Physical therapists mostly focus on the reflex, stationary, locomotion, and object manipulation portions of the PDMS-2.  Through these sections of the test, we can better assess 1) the maturation of a baby’s neuromuscular system, 2) his safety and stability when navigating his environment, 3) his ability to support and move his own weight, and 4) his ability to maintain his balance and control his trunk while moving objects outside his center of gravity. Overall, this tells us how well a child can use the large muscles in his body to stabilize and create movement.

The Peabody Developmental Motor Scale has been norm-referenced, and proven to be reliable and valid. It has been used to monitor children with and without developmental difficulties. It is relatively easy to administer and the information it provides can be used by medical professionals to tailor a child’s individualized education program (IEP).

Does your toddler have special needs? Or do you have questions about physical therapy screenings for your preschooler? Come to see one of our specialists!

boy with truck

W-sitting and the Young Child

Chances are, if you know what W-sitting is, you or someone you know sits just like that. Occupational, physical, and developmental therapists often express their disapproval whenever they see a child sit in this position. More and more parents are catching on to the fact that this is a posture to keep their children out of. The most common questions they have are 1) why is it so bad? and 2) what is there to do to help change this habit?

What is W-sitting?

Many children with low muscle tone, decreased core strength, increased joint laxity, or hip instability, will sit and play with their knees together, bottom on the floor, and feet out to both sides.

Why do some children like to sit this way?

Simply put, a young child’s joint and bone structures will allow them to sit in this position. Certain medical diagnoses, such as Down syndrome and femoral anteversion, are often associated with this preferred sitting posture. In this position, children are more comfortable and don’t have to work as hard to hold their trunks upright. Instead, they are spreading their lower limbs out over a wider base of support, thus relying on their joint structures and not their muscles, to hold them up to play.

Why do therapists recommend against it?

While the knees together and feet out position is fine as a transitional position, our hips are not designed to be in the W-sitting position for a long period of time. Prolonged sitting in this position places significant stress on inner hip muscles and joint structures. The young musculoskeletal system will then develop in such a way that just creates more and more instability of the hips. If a child gets used to sitting and playing in this position, weaknesses and orthopedic misalignments will only travel up and down the musculoskeletal chain. Children who W-sit well into their preschool to school years often experience decreased trunk strength, poor attention, in-toeing, poor posture, clumsy coordination, and frequent loss of balance.

How to help a child out of the position?

Many parents would tell me that they are at their wits’ end, constantly instructing their child out of the W-sit position.  While repetition and consistency are key, habits are difficult to change, especially with verbal reprimands alone. Change things up and give your child other sitting postures as options:

1) The most common alternate position is with feet crossed and knees apart. “Criss-cross applesauce” is what we usually tell children when we see them W-sitting. They respond well to this simple cue.

2) Side-sitting is a great alternative if sitting with knees out is too difficult. In side-sitting, both knees are bent, weight is shifted to one hip, and both feet are out to the same side. This takes away stress from the hip joint structures, allowing for easy transitions in and out of sitting.

3) Long sitting with feet forward and back supported is a great way to stretch out those hamstrings and keep hip/knee joints in neutral.

4) If a child has a hard time sitting and playing, I let them kneel with their feet tucked together under their bottom. As long as they don’t slowly shift back into the W-shape, kneeling is a great position to strength their hip and core muscles.

5) Half-kneeling with one foot tucked and the other foot flat on the ground will keep the hips in neutral alignment. In this position, muscles will be active and hip joint structures will not be put under damaging stress.

6) Finally, squatting or sitting on a low chair will also help keep a child out of W-sit during play.

If you are still looking for ways to keep your child out of this injurious habit, talk to a therapist. Physical therapists will come up with ideas and exercises tailored to each individual child and find the best ways to improve his or her posture and alignment.




Dizzy Kids

What Is The Vestibular System

Most kids learn about the 5 basic extrinsic senses of sight, sound, taste, touch, and smell. Many, however, are not as familiar with two hidden intrinsic senses: the vestibular and proprioceptive senses. The vestibular sense is one of the first to develop in a growing fetus and is stimulated by the movement of a carrying mother’s body. By only 5 months in utero, this system is well developed and provides a great deal of sensory information to a growing fetal brain. This system is very important to a child’s early development. Its role is to relay information to the brain as to where a person is in space, as related to gravity; whether they are moving or still, if they are moving how quickly, and in what direction. The vestibular system gathers that information from a set of fluid filled canals and a sac-like structure in the inner ear. These structures respond to movement, change in direction, change of head position, and gravitational pull.

  4 Ways the vestibular system may impact your child:

1. The vestibular system coordinates eye and head movements. Without this coordination, it may be challenging for children to complete everyday activities such as copying from a white board in their classroom, following a moving object such as a softball through the air; or visually scanning across a page to read. The vestibular system helps the brain to register and respond to whether the object the child is looking at is moving or if their head is moving.

2. The vestibular system also helps to develop and maintain normal muscle tone. Muscle tone is the ability of a muscle to sustain a contraction. Without a proper functioning vestibular system, it may be challenging for a child to hold their body in one position. These children may oftentimes prefer laying on the floor instead of sitting up during circle time or leaning on their elbow or hand while seated at their desk.

3. The vestibular system also impacts a child’s balance and equilibrium. As your child moves throughout their environment, so does the fluid in their inner ear canals. As the fluid in their inner ear moves, your child’s brain is receiving information as to the position of their head in space. Depending on that signal, the brain then sends a message to your child’s body signaling it to move in a way that will help them to respond to and compensate for any planned or unplanned movements.  Without efficient vestibular processing, your child may appear to be clumsy and have trouble staying on their feet during routine play.

4. Finally, the vestibular system helps a child to coordinate both sides of their body together for activities including riding a bicycle, catching a ball, zipping a coat, or cutting with scissors.

If you suspect that your child is having difficulty processing sensory information by way of their vestibular system, do your best to be sure that activities including a lot self-propelled movement are incorporated into their day. Activities may include swinging, sliding, or using other equipment at the park. Do your best to avoid activities with excessive spinning or twirling as movement in these planes can have negative effects including over-stimulation, lethargy, or changes in heart rate or breathing. It may also be challenging for your child to pace themselves during these quick paced movement patterns. Encourage activities in which your child lays on their belly to participate in games or play with toys. Throughout your day, take note to see if your child seems better able to focus after completing physical activity or partaking in activities that get them up and moving.

The vestibular system may be less commonly discussed than other sensory tracts, but its impact on your child’s ability to complete day to day activities are vast.


Baby crawing

Common Physical Therapy Red Flags at Pediatrician Well-Visits For Baby’s First Year

First time parents don’t quite know what to look forward to when visiting their pediatricians during their child’s first year. Other than immunizations, growth measurements, and nutritional concerns, what else is there to discuss? Each well-child visit is a brief meet-up to assess the child’s growth and development. A red flag is an early warning sign that something is not developing typically and need to be addressed by a specialist.

Below are some physical development related red flags to discuss with your doctor on each of your child’s well-visits. Any one of them could warrant a follow-up visit to a physical therapist to ensure appropriate gross motor development. Early detection and early intervention is important and many red flags should not be dismissed.

1 month

– If your baby prefers to sleep with his or her head turned to one side, be mindful of a flat spot that might start to develop. Switch the side she lies on in her crib and alternate the direction of stimuli.

– Babies at this age should hold their limbs and trunk in some flexion, with random movements here and there. If your baby prefers to lie limply on his back with every limb spread out, pushes into extension with trunk and limbs that seem to stiffen up with every movement, or show difficulties with moving his or her head side to side, bring it up with your pediatrician.

2 months

– If you continue to notice a flat spot or a head turn preference when your baby sleeps on her back at month two, it might be good to bring it up with your doctor.

-At this time, babies are gaining more and more strength in their neck muscles.  In sitting, their heads are more upright though continues to bob. If you don’t see your baby using his or her neck muscles at all, it may be a sign of slow development.

4 months

-This is the month of increased symmetry. If your baby continues to prefer to sleep, sit, and play with head only to one side, try to encourage him or her to play with their head in midline.

-A baby on his tummy at 4 month should be able to push up onto his arms and hold his head up.  Red flag behaviors to ask your doctor about include: difficulty lifting head up, stiffening in his legs with little or no movement, pushing back with his head as opposed to lifting it forward when trying to roll, and fisted or lack of arm movements.

6 months

-At 6 months, a babies are sitting up and holding themselves up in sitting. They can also roll without help.

-Red flags at this stage are signs that point to difficulties with these tasks, such as: no trunk or head control in supported sitting, increasingly stiff back and legs, or inability to bring arms forward to reach for toys.

9 months

-A 9-month-old can sit and reach for toys without falling. He can move easily from lying down on his back or his tummy to sitting on his bottom.

-If your 9-month-old sits with his trunk leaning forward, doesn’t reach out to play with toys, uses one side more than the other, seems to drag one side to move, doesn’t crawl, and cannot take any weight on his feet when you prop him up, please bring it up with your pediatrician at his 9 months well-visit.

12 month

– Of course every baby develops differently. But by 12 months, a typically developing baby should be able to pull to stand and cruise along furniture. She might be able to stand alone and take independent steps.

-What we as physical developmental experts look for is fluidity of movement. If a child has difficulty getting to standing because of stiff legs, extended trunk, weakness on one side, or pointed toes, that is cause for a more in-depth look. If your baby only pulls up to stand with his arms instead of using his legs, it is definitely good to make your pediatrician aware.

-If your child sits with weight mostly to one side, needs her hands to maintain sitting, holds any part of her limbs stiffly in extension or flexion, or has difficulty moving between positions by her 12 month visit to her pediatrician, please ask about a physical therapy follow-up.

18 months

-A big indicator of need for physical therapy is if a child still cannot stand or take steps independently by 15 months.

-Red flags at the 18 months well-visit include: inability to stand and step independently, frequent falls while standing, poor standing balance, difficulty squatting, or walking predominantly on toes.

 

The warning signs and red flags mentioned above are meant as a guide to parents. If your child is showing these signs and is not achieving his or her gross motor milestones on time, do not focus so much on a medical diagnosis. What is important during the first year is that your pediatrician is aware of differences in your child’s development and recommend specialist follow-up as needed.

To see what your child should be doing at later stages in life, download our Gross Motor Milestone Checklist here.




 

boy learning to walk

Gait Development In Children

A majority of my clientele are babies just learning to walk, toddlers who are delayed in their walking, or preschoolers who are showing an abnormal gait pattern. Years ago, when I worked in the rehabilitation and hospital settings, most of my patients were trying to regain their ambulatory abilities after an injury. Needless to say, walking is an important part of growth and locomotion. It is a complex task that requires musculoskeletal and neurological system maturation and cohesion.

Development of Gait:

The components of typical adult walking include 1) stability in stance, 2) sufficient foot clearance, 3) appropriate positioning of foot for initial contact of the next step, 4) adequate step length, and 5) energy conservation. Depending on the age or type of injury, a person’s walking ability might be impaired in any of these factors. Physical therapists work to address each component to encourage efficient and safe walking.

At age 1, children are just learning to walk and are still working on their standing stability. When they first start walking, their arms are held up high in protective guard, and they walk really fast so as not to lose their balance.  They rely on a wide base of support to maintain their stability. They often put their feet down flat on the ground and they do not spend as much time on each leg when clearing their feet for the next step.

About 6 months later, children will often start walking with a more natural gait, with arms down in a reciprocal swing, and with heels hitting the ground first.  Because of the structure of toddlers’ bones and joints, they still stand with a wider base of support than adults do, but are in the process of narrowing their stance.

In preparation for running efficiency and coordination, children who are two years old will have better ability to stand on one leg while clearing the other foot, and they are better at lifting their legs up and forward during walking. Base of support will continue to narrow during this stage.

By three years of age, children have gained the strength, upright posture, and limb coordination to walk similarly to adults. They might still stand and walk with different joint motions than adults, but this is more due to structural differences than anything else.  As their muscles and bones mature, children’s ambulatory abilities will improve as the forces of gravity and daily activity slowly elongate and strengthen the structures needed to perform adult walking. Of course someone who is seven years old cannot walk with the same speed and step length that an adult can, but they come pretty close.

The orthopedic and neurological changes that occur in a baby to enable him or her to walk are complicated.  It takes years and lots of practice for a mature walking pattern to develop in a child. Parents often ask whether or not their child is walking “normally.” That analysis depends on the child’s age, medical history, and family history. Studies have shown that adult gait is present in children by 7-8 years of age. A child can come into physical therapy with a variety of deviations (from flat feet, in-toeing, to toe-walking, to frequent falling). It is only through careful observation and assessment of their gait cycles that physical therapists can help these children achieve the optimal pattern.

Reference:

Stout, JL. Gait: Development and Analysis. In: Campbell SK, eds 3. Physical Therapy for Children. Philadelphia, Pa: WB Saunders Co,2004 :161-167.

Keen M. Early development and attainment of normal mature gait. Journal of Prosthetics and Orthotics 1993; Vol 5, Num 2, p 35. Available from: http://www.oandp.org/jpo/library/1993_02_035.asp; 2014 [accessed 31 March 2014]






Arm with kinesiotape

What is Kinesio® Tape and why is it used on children?

Physical therapists and occupational therapists often use Kinesio® Tape on their clients as an adjunct to therapy. So what is Kinesio® Tape? You might have seen this colorful tape on Olympic athletes in various locations and various patterns. It is an elastic tape that has multiple purposes depending on where and how it is applied. It is often used to reduce pain, swelling, improve strength, encourage optimal alignment, and decrease muscle fatigue.  Kinesio® Tape can be used at full tension like regular athletic tape. However, it is the elastic qualities of Kinesio® Tape that make it therapeutic.

Properties of Kinesio® Tape:

-Latex free
-Variable tension depending on function
-Adhesive is medical grade acrylic and heat sensitive
-Allows for free movement instead of restricted movement like regular athletic tape
-Similar elasticity as human skin, so it can stay on for days to maximize its full effect

Purpose of Kinesio® Tape:

-To hold a joint in optimal position to help an overstretched or overworked muscle to rest and return to its most efficient length.
-Keeping a body part in better alignment helps the muscles contract and work in a less stressful fashion during daily activities.
-To increase input to the skin around a specific muscle or joint. With this new proprioceptive input, more awareness of that body part leads to more strength.
-To help relax an overused muscle which helps reduce pain and swelling
-Improve lymphatic flow and reduce edema and bruising, allowing for accelerated healing

Who can benefit:

People with a variety of orthopedic, neuromuscular, or medical conditions, such as:

-Cerebral Palsy
-Conditions with weakness or paralysis of a certain body part
-Down Syndrome
-Gross Motor Developmental Delay
-Children with gait abnormalities such as toe-walking, flat feet, hyperextension, etc.
-Low muscle tone
-Decreased coordination
-Brain injury
-Torticollis
-Lymphedema
-Painful orthopedic injury
-Poor posture
-And many more…

Not only is Kinesio® Tape safe for use on children, I have found Kinesio® Taping to be extremely beneficial and valuable to my clinical practice.  This elastic tape can be left on for 3-4 days after application. Often times, I put it on at the end of a session to help my clients retain the gains we made during the session. In a way, it improves carryover from week to week, and brings the physical effects of therapy home. With babies, this “reminder” is especially important, as they are still working on their neuromuscular control and cannot make a conscious effort to contract a certain muscle or hold a specific position during their play activities. With children, the colorful tape gives them a fun visual cue to increase use of a certain body part and strengthen those all important neuromuscular connections.

Reference:

Kase, K, Martin, P, Yasukawa, A. Kinesio®Taping in Pediatrics. 2006. Kinesio® USA , LLC. 16-19.


Gross Motor Skills and Dance

Dance has always been a fun and exciting recreational activity for children of all ages. Along with the enjoyment of dancing to upbeat music and the social experience, dance is also a great way to help develop your child’s gross motor skills. Read on for 4 aspects of your child’s motor skills that can be facilitated with dance lessons and performance of any style.

4 Gross Motor Benefits to Dance:

  1. Balance-Many dance moves incorporate balancing on one leg, standing with feet right next to each other or standing with one foot in front of the other. All of these positions are challenging for your child’s balance systems, which help to strengthen her balancing abilities.
  2. Coordination-While learning to dance, your child will begin by learning different dance moves and positions. Most positions involve different placement of all 4 limbs, which requires a lot of coordination. Also, once your child learns a dance routine with multiple dance positions sequenced together, she will need to coordinate the entire routine. Read more

Make the Most of Pediatric Therapy Sessions

Parents often ask how they can help their child make optimal progress while in therapy.  Attending therapy once or multiple times a week is a large commitment, both financially and time-wise.  Therefore, it’s important to make the most of your child’s time in therapy and to ensure you optimize your resources to help your child progress as much as possible.

5 Things parents can do to make the most of pediatric therapy sessions:

  1. Communicate with your child’s therapist.  If you don’t know what your child is working on in therapy, then there is a problem.  Your therapist should continually inform you what specific goals your child is working on and why.  Your therapist should also give you specific ways to address these goals at home.  If you feel unsatisfied with the communication between you and your therapist, talk to him or her about it.  Troubleshoot ideas to open the lines of communication, whether it’s talking at the end of treatment sessions, planning periodic phone meetings, or receiving e-mail updates.
  2. Check-in about the big picture.  In addition to weekly communication with your child’s therapist, schedule time every so often for a more thorough “check-in” meeting about your child’s progress and to collaborate on a plan moving forward.  This might be a face-to-face meeting or a phone conference.  These are best done without the distraction of your child or other siblings present.  Discuss your child’s progress, ask your questions, and get an idea of where things are going from here.  Is your child making progress?  If not, why?  Should therapy be increased to twice a week?  Will your child benefit from additional support from another therapeutic discipline? Read more

Zumba for Kids

We all know the many benefits of exercise for people of all ages: physical fitness, endurance, strength, coordination, and zumba for kidsmotor planning.  However, making physical fitness a regular part of daily routines can be a real challenge not only for adults, but also for children.  Many children who live more sedentary lifestyles require more motivation to get moving, since it has become their habit to be still.   So what is the trick to increasing kid’s enthusiasm for fitness and getting sedentary kids off the couch?  It’s simple: FUN!  Fitness for children, just like any other children’s programming, should be fun, socially appealing and inviting!

A common activity that many families find enjoyable for all ages is Zumba!  Zumba is a dance-fitness combination that includes culturally diverse music and various elements of dance and cardio, including Hip Hop, Latin dancing, and traditional aerobics.  Zumba is a wonderfully unique fitness program that is set off by its enjoyable, party-like scene.  The bright, bold wardrobe colors, loud music, and rhythmic beats create an energetic and enticing place to get fit.  Zumba is also great for kids! Read more