Gait Development In Children

Walking is an important part of growth and locomotion. It is a complex task that requires musculoskeletal and neurological system maturation and cohesion. Read here on how early gait develops in children.

via Gait Development In Children.

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The Different Types and Presentations of Cerebral Palsy

In last month’s blog about cerebral palsy (CP), I talked about the neurological condition and what can be improved by working with a physical therapist. This week, I am going to delve deeper into the condition and explain why some kids with CP are so different from one another.

Cerebral palsy has many classification systems. Medical professionals use these systems to understand and manage a child’s symptoms and help plan their treatment.

As stated previously, cerebral palsy describes a brain lesion that occurred in utero or around the time of birth.   Much like a brain injury, CP can be classified based on severity level, location of lesion, body part affected, change in motor control, and how gross motor function is affected.

body map

Classification of CP Based on Level of Severity:

This is a common method of categorizing children with CP, used by doctors and parents alike, though it provides relatively little information. Parents and doctors use this classification system as a simplified communication tool to describe the exact level of impairment.

  • Mild: Having mild CP means a child can move independently and without assistance from people or equipment. He can complete his daily activities without any limitations.
  • Moderate: A child with moderate cerebral palsy will need braces, medical interventions, and adaptive equipment to do functional things, such as walking and keeping up with peers.
  • Severe: A child who will require a wheelchair and who will need quite a bit of assistance to accomplish daily activities is said to have severe CP. Often times, severe cases have multiple equipment needs, and simple things such as eating or sitting alone can be a challenge.
  • No CP:  Some children display cerebral palsy signs though the brain injury occurred after the time of birth, and therefore is classified under traumatic brain injury or encephalopathy.

Classification Based on Topographical Distribution (Body Part Affected):

When trying to plan treatment protocol for a child newly diagnosed with CP, many therapist and pediatricians like to know which body parts are affected and how they are affected. Is one limb weakened (paresis) or paralyzed (plegia)? How many limbs are affected that way?

  • Monoplegia/monoparesis – Only one limb is affected.
  • Diplegia/diparesis – When the legs and the lower body are more affected than the arms
  • Hemiplegia/hemiparesis – The arm and leg on one side of the body are affected.
  • Paraplegia/paraparesis – Only the legs are affected.
  • Triplegia/triparesis – When 3 limbs are affected, or 2 limbs and the face
  • Double hemiplegia/double hemiparesis – All four limbs are affected, but one side of the body is more affected than the other.
  • Tetraplegia/tetraparesis – All 4 limbs are affected, but three limbs are more affected than the fourth.
  • Quadriplegia/quadriparesis – All four limbs are impacted.
  • Pentaplegia/pentaparesis – All four limbs involved, as well as the neck and head.

Classification Based on Motor Control:

What is motor control? It is the body’s ability to voluntarily control limb and joint motion.  Muscles are controlled by the nervous system and abnormal contractions (too much or too little) often occur with brain lesions. Cerebral palsy is often a complex condition. It is possible to have variable muscle tone or a mixture of motor control presentations.

Spastic CP – indicates increased muscle tone, the most common type of cerebral palsy.
Non-Spastic Cerebral Palsy – characterized by low muscle tone or fluctuating muscle tone, or involuntary movements.

When muscle tone is affected, the movements and power needed to move the joints are often affected as well.

Hypertonia/hypertonic – describes increased muscle tone and is often associated with spastic cerebral palsy.  The child may present with stiff limbs, muscles that seem tight, or decreased ability to open his hands or straighten a limb.
Hypotonia/Hypotonic – often used to describe low muscle tone, and can be seen in diagnoses outside of CP. A child’s limbs or trunk may seem hard to control and “floppy.”

Some children’s cerebral palsy can actually be mixed in presentation, where some limbs are affected by spasticity and others are non-spastic.

Classification Based on the Gross Motor Function Classification System (GMFCS):

The last system of categorizing CP is a five-level system that describes the severity of impairment and limitations a child experiences with the condition.  Higher numbers mean a child is able to achieve less activities on his own.

GMFCS Level I – the individual walks without limitations
GMFCS Level II – walks with some limitations, including long distances, running, jumping, and balancing.  They may need devices when first learning to walk, up to age 4, and may need wheeled mobility when travelling long community distances.
GMFCS Level III – walks with an adaptive device.  Assistance is needed to walk indoors and wheeled mobility needed outdoors.  The individual can sit independently or with some external support.
GMFCS Level IV – the child is independent with powered mobility (motorized wheelchair) though need support when sitting. He may be unable to push himself in manual wheelchair.
GMFCS Level V – the individual shows significantly limited head and trunk control. Much of his mobility will need assistive technology or physical assistance.

A more expansive copy of the GMFCS system can be viewed here.

Why so many classification systems?

Most cerebral palsy specialists, health professionals, and parents will need guidance and direction when approaching a child with cerebral palsy. Knowing whether or not a child has low or high tone will determine equipment needs. Knowing the severity level will help physicians plan out need for future treatments and care options.  Understanding whether a child has spastic or non-spastic CP will help tell neurologists and neurosurgeons which part of the nervous system is affected. Having a better grasp on the type and location of lesion will help the medical team prepare for long term associated conditions of cerebral palsy, such as hip dislocation, scoliosis, joint contractures, or seizures.   It is important for therapists to know whether a child with CP has difficulties with muscle tone, muscle control, hand-eye coordination, balance, stiffness, or muscle strength.

The Gross Motor Function Classification System (GMFCS) is used by researchers and clinicians alike and is applicable to all types of cerebral palsy. While other classification systems describe what a child is limited by, the GMFCS places more emphasis on what a child can accomplish. Therefore, parents can use this system to understand how their children will progress over time.

Classification is very important in the treatment of the young child with cerebral palsy, and multiple classification systems help therapists and specialists create individualized plan of care for those children and families impacted by the condition.

Reference:
Types and Forms of Cerebral Palsy. MyChildTM at The Cerebral Palsy Organization website. Available from: http://cerebralpalsy.org/about-cerebral-palsy/types/; 2014 [accessed 18 March 2014]

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An Uplifting Syndrome

In light of World Down Syndrome Day, which was 9 days ago, I was preparing to write a work blog about the physical limitations of children with Down Syndrome and what we can do as therapists to help them lead better lives.

Then I stumbled upon this video. Created by an Italian advocacy group.

It gave me goosebumps. Because of the truth spoken by these wonderful children. Because the smiles on their mothers’ faces. It puts things in perspective; not just for families with children with Down Syndrome, but for families with children of all abilities.

“Sometimes, it will be difficult. Very difficult. Almost impossible. But isn’t it like that for all mothers?”

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WORLD HEALTH ORGANIZATION DEVELOPMENT STUDY RESULTS: GROSS MOTOR MILESTONES IN THE FIRST YEAR

The line between typical and atypical development can be a hazy one. There are standards that pediatricians, physical therapists, and developmental experts use to monitor growth and deviations from the norm, which allow us to recommend interventions when appropriate.  In 2006, the World Health Organization (WHO) released a whole new set of standards for evaluating and assessing the development of children from birth to 5 years.

 

Gross Motor Skills

What makes this new standard a great tool to monitor the change and growth of infants? This standard is based on data collected from healthy children, over multiple years, in six diverse geographic regions including Southeast and Southwest Asia, Europe, West Africa, North and South America. What is exciting about the new evaluation tool is that now, pediatric specialists have more than just reference curves for physical growth, but curves for motor development as well.

THE SIX GROSS MOTOR MILESTONES WHO EXAMINED IN BABIES WERE THE FOLLOWING:

1.    Sitting without support
2.    Standing with assistance
3.    Hands-and-knees crawling
4.    Walking with assistance
5.    Standing alone
6.    Walking alone

The “windows of milestone achievement” were organized into percentile rankings which pediatricians and physical therapists can use, much like a growth chart.

Without Delving Too Deep Into Statistics And Calculations, The Typical Age Range (In Months) For Each Milestone Is Listed Below:

1.    Sitting without support: 3.8 – 9.2 months
2.    Standing with assistance: 4.8 – 11.4 months
3.    Hands-and-knees crawling: 5.2 – 13.5 months
4.    Walking with assistance: 5.9 – 13.7 months
5.    Standing alone: 6.9 – 16.9 months
6.    Walking alone: 8.2 – 17.6 months

The Average (Mean) Age For Healthy Children Achieving Each Milestones Is As Follows:

1.    Sitting without support: 6 months (with 1.1 month standard deviation, SD)
2.    Standing with assistance: 7.6 months (with 1.4 month SD)
3.    Hands-and-knees crawling: 8.5 months (with 1.7 month SD)
4.    Walking with assistance: 9.2 months (with 1.5 month SD)
5.    Standing alone: 11 months (with 1.9 month SD)
6.    Walking alone: 12.1 months (with 1.8 month standard deviation)

(Click here to view this information in chart form from WHO.)

What is most interesting is that about 90% of the children studied met their milestones in a common sequence, and only 4% of the children skipped hands-and-knees crawling.  (Read here about the importance of crawling.)

As you read over these standards and timelines, remember that every baby develops differently from another. If you see your baby fall behind on any of the 6 gross motor milestones above, mention it to his pediatrician, and she will most likely recommend a physical therapist to help him along.

Reference:
WHO Multicentre Growth Reference Study Group.  WHO Motor Development Study: Windows of achievement for six gross motor development milestones. Acta Paediatrica, 2006; Suppl 450: 86-95.

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Jumping as an Important Milestone

Sometime between the 18th and 24th month, children start learning to jump. Eager parents often ask when to expect their child to jump with both feet off the ground. The simple answer is, every child is different. Of course, we as physical therapists and developmental experts will become concerned if a child is still making no attempts to jump by 2.5 to 3 years. However, what parents should know is that there are many reasons a child could be delayed on a particular gross motor milestone.
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Usually, after 6 months of walking independently and participating in typical play (such as climbing on/off furniture, walking up and down stairs with help, and running on various surfaces) a child will have developed the strength and balance needed to jump without falling. When she first starts jumping, she might push off with one foot only and jump down from a low step without help.  By 2 years, a typically developing child can most likely jump forward 3-4 inches while maintaining her balance, with both feet.  She should also be able to bend her knees, with feet together, and propel herself upwards to try to touch something up high.
jumping

WHEN TO SEEK PHYSICAL THERAPY INTERVENTIONS:

Around 2.5 years of age, if your child continues to show difficulty with jumping and shows any of the following, it is best to bring her into physical therapy so we can check out her alignment, strength and balance, and give her strengthening exercises as needed.
  • Asymmetrical jumping: A typically developing child does not show side-preference until preschool age. If you notice your child always pushing off and landing with one side, seems to drag one side or hold it stiffly, or if one side barely participates in the initiation of jumping, it’s good to mention it to your doctor at her 24 months check-up.
  • No power during push-off: If your child prepares to jump by initiating a squat but then her feet barely leave the floor, her leg muscles may not be strong enough yet to fully propel her weight forwards or upwards.  Or, she might not know how to best coordinate the beginning and end of the activity. If she prefers to step off a low surface or step over an obstacle instead of jumping, she is showing weakness in her legs, especially her thigh and hip muscles.
  • Frequent falls: If she crumbles to the floor or if her knees buckle every time she lands from a jump, or if she falls on purpose when trying to jump, your child may be showing that her body is just not ready for this milestone.
  • Increased anxiety or behavioral resistance to the task: Does your 3 year old hesitate with apprehension, ask to be picked up, or ask for a hand any time she’s encouraged to jump down or over something on the ground? Does she throw a tantrum or flops to the ground if you don’t help her?
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All of the above could mean something is keeping a child from jumping. There could be a visual discrepancy or a depth perception issue that can be addressed with occupational therapy, an anxiety/comfort matter that can be addressed by social work, or a deeper issue that can only be attended to after a thorough evaluation by a developmental expert.
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What physical therapy means for a child with cerebral palsy.

For new parents whose children are diagnosed with Cerebral Palsy (CP) and parents whose children with CP are nearing school age, understanding the diagnosis, prognosis, and the interventions available is often their top priority.  Being a first-time parent is challenging enough, and for many parents looking for answers, a medical diagnosis provided by a doctor often leads to more questions.

WHAT HAVING CEREBRAL PALSY MEANS FOR YOUR CHILD:

Cerebral Palsy is a broad term used to describe a neurological condition that impacts physical functioning in children. The presentation of CP in individuals affected is highly varied in terms of severity, symptoms, and deviation from typical development.  The condition itself is explained by a brain lesion that occurred in utero or around the time of birth (such as an in-utero stroke, brief oxygen deprivation before birth, or a birth trauma to the young brain).   The neuromuscular system is affected, leading to motor impairments that hinder a child’s voluntary muscle control. Put simply, a child’s ability to control his trunk and move his body parts become limited.

Muscles and our brain’s ability to control them are a huge part of our physical function, from our vision and speech, to our sense of balance. This impaired control and coordination of voluntary muscles affects children in a variety of ways, depending on the location, timing, and severity of the brain lesion.  Much like a brain injury can affect a mature individual’s ability to control his limbs, a lesion in the immature brain often leads to decreased postural control and delayed physical development.  The lack of motor control is sometimes, though not always, correlated with cognitive delays and learning disabilities, speech delays, visual or auditory impairments, and seizure disorders.

There are many misconceptions in the general community about children with CP.  Many people think CP is associated with mental delays and poor independent functioning. This is simply not the case for everyone with cerebral palsy.  Cerebral Palsy is often classified in different ways based on the movement disorder (stiffness, rigidity, low tone, uncontrollable movement, etc) observed. No matter the diagnosis or presentation, a team of healthcare professionals is absolutely essential to improve the lives of children and families affected with cerebral palsy.  It is important to begin a treatment program as early as possible to ensure a child develops to his or her full potential.  Sometimes, a child with CP may need surgery, orthotics, assistive technology, early intervention therapy, or medications, to improve their function and independence.

THE ROLE OF THE PHYSICAL THERAPIST:

One of the first steps to take after receiving a diagnosis of cerebral palsy is to discuss with your pediatrician and your child’s medical team about the interventions currently available and the interventions needed long-term. Often times, physical therapy becomes an indispensable part of a child’s medical care. Physical therapists will develop a plan of care based on the child’s abilities.

Our Goal As Physical Therapists Is To Improve A Child’s Independence By:

  • Teaching him to move and play while protecting his joints from abnormal movements/postures
  •  Helping him strengthen muscles that are weak, keep stiff joints mobile, and stretch out muscles that are tight
  •  Fitting him for special equipment to help him stand, walk, and participate in school and life activities as needed
  •  Working with his family and caregivers on adaptive techniques and changes to their home or school environment, to allow him to interact with other children and participate in daily tasks
  •  Addressing his limitations and movement disorders by improving his posture, walking mechanics, endurance, and pain
  •  Accommodating for his changing needs as he matures and as new challenges arise, and
  •  Providing the child and his family emotional support, healthcare references, and professional insight to help him transition into adulthood.

Every child with cerebral palsy develops differently. The importance of early therapy is to help a child live up to his full potential with this neurological condition.

Reference: Olney SJ, Wright MJ. Cerebral palsy. In: Campbell SK, eds 3. Physical Therapy for Children. Philadelphia, Pa: WB Saunders Co, 2004 :625-664.

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6 Health Benefits of Basketball for Children

basketball, physical therapy

Ever wonder which team sport keeps boys and girls busy no matter their age, skill level, or the season? I recently had the opportunity to watch one of my clients play basketball with his middle school team, and it was so rewarding to see him transfer skills we worked on during physical therapy to the court.  Basketball is a high-intensity, high-agility activity that teaches children coordination, concentration, and cooperation.

6 HEALTH BENEFITS OF BASKETBALL:

  1. Endurance: As with any high intensity sport, there are many cardiovascular benefits of basketball.  Between bouts of running, jumping, dribbling, and bouts of rests, kids are participating in total body interval training without even realizing it. Interval training boosts aerobic capacity, energy levels, and metabolism, which in turn helps kids concentrate more in school.
  2. Motor Control: The ability to control our limbs in space may come naturally, but being able to pass and shoot with precision during a basketball game takes special training and repetitive practice.  Performing drills on and off the court with a basketball enables children to grade their muscle forces, control the position of their bodies in response to an opponent or a pass, and plan out successful movement sequences.
  3. Ankle Stability: All the agility training, cutting back and forth, multidirectional running, pivoting, and turning within a basketball game are great ways to challenge our lower body muscles and joints, especially the structures surrounding our ankles.  Organized basketball teaches kids safe and successful ways to block, pass, steal, jump, and run without hurting themselves or others.  Ball sports such as basketball are great for reinforcing kids’ balance reactions and balance strategies and prevent future injury.
  4. Balance/Coordination: As with most team sports, basketball requires upper body coordination, total body coordination, and hand-eye coordination. Dribbling, catching, passing, and making baskets require planning, precision, and quick reactions. Walking backwards, turning, or running while dribbling a ball and at the same time paying attention to other players is a challenging but interesting exercise for coordination and body awareness.
  5. Agility: Basketball is a fast paced sport where athletes have to think fast on their feet and respond quickly to plays that could change momentum and direction at any minute.  Young athletes are working on mental drills in addition to physical techniques. Basketball enhances children’s agility due to the swiftness needed to dodge other players and make aggressive plays.
  6. Social Skills: The great thing about team sports is the level of discipline and communication needed for success at the games. Young athletes learn from an early age how to work in a team atmosphere, pay attention to others, and respond accordingly. An athlete needs discipline to attend practices and pay attention to the rules of any game.  Team sports prepare children for necessary social interactions later in life.  Through these sports, children understand shared responsibility, team work, how to deal with triumph and defeat, all of which are applicable throughout life.
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Putting Parents on Tummy Time

Chances are, if you like babies, you’ve seen this recent video floating around the interwebs:

What I, a pediatric physical therapist, personally love about this video, is that it encapsulates everything I always tell parents about promoting tummy time for their babies.  Any new parent knows, tummy time is tough. Babies hate it.  But it is something essential to their motor development. Here is what this dad did right to help his baby daughter along, and why it means little Lilly Ann will grow up physically healthy and strong:

1. Spending time on the floor – Getting down on the floor with your baby, whether or not she is your only child, is the best thing for her development. Being on eye-level with her and putting your face close to hers will stimulate her senses and allow her to enjoy tummy time just that much more.

2. Acting like a baby – You know the saying that kids grow like weeds? It’s true. One second they are crawling and drooling, and the next second they can walk, run, and participate in conversations. Take advantage of these moments where you can act silly. Unabashedly silly. It’s part of what makes parenting fun.

3. Praising it by bringing attention to it – Sure, you don’t have to post every milestone your baby makes on the social media sites. But what Lilly Ann’s dad noticed, and then celebrated, was something so simple yet so fundamental in a baby’s growth. Having the strength and the ability to lift her chest up over and over again, even though her arms fatigued here and there, means Lilly Ann is trying. If that’s all she is able to do on tummy time at that moment. So be it. Embrace it.

Wondering the importance of tummy time for babies? Check out my previous work blog on tummy time during the first year. http://nspt4kids.com/parenting/tummy-time-the-first-year-a-month-by-month-primer-north-shore-pediatric-therapy/

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