Playing with your baby physio style

So your baby is starting to have some awake time, and looking up you with their wide eyes expecting you to entertain and play with them… What should you do??

Sometimes just place them on the floor nearby and watch them kick their legs, punch the air with their fists, discover sucking their hands and then even cooler sucking their own toes!

Yep leaving them on the floor in safe place, to learn about where there body ends and the world begins, is therapy approved parenting!

Read on for other fun activities you can do to help them in their quest to ‘colour in their body map in their brain’ – which is building the foundations for so many exciting things to come (including being able to self-regulate -which is just a fancy therapy way of saying calm themselves down!!!):

In the first few months it’s all about sleep, milk and getting those poops out! But even with all that going on babies have to find the time to start to make connections in the brain to register and organise things they are sensing – most importantly at the beginning sensations like pressure, pain, temperature, position, movement, vibration (somatosensory system – just to throw in a big word so you remember I’m a Physio), alongside hearing and vision.

So you can help them by being aware of what activities and environments provide what type of sensory input as the only way to learn to process different types of sensory input is to experience it.

Everyone, baby, child and adult will have a different threshold (tolerance) to different types of sensory input.  So helping them to experience a certain movement, or sound or touch in a safe way will enrich their sensory body map. You might be increasing their threshold so they can cope better in a certain environment (a busy noisy train); an activity (having a bath or nappy change). Or conversely you may be helping them reach a higher threshold – if they aren’t noticing, responding (registering) a certain sensory input yet, by repeating it or playing it louder, bringing it closer you send stronger input until the threshold is reached and the information is sent up the pathways and registered in the brain. Experience is the only way to establish and then reinforce the pathways.

So many sensory pathways are being made in the first few years of life, we don’t keep them all! So if your little one starts to explore independently they will keep strengthening the pathways and experiencing more and more, building on those foundations. However if they are not able to explore in a broad a varied way due to a motor relay or neurological impairment then they will reliant on you make it possible to keep exploring and reinforcing the foundation’s, even when they are also working on acquiring and mastering higher level skills.

These are some activities/ play ideas that all babies can enjoy and will benefit from experiencing:

Activities and positions to encourage:

Just being on the floor – babies do very important learning just being left in a safe place to move their arms and legs, to look at their hands and reach for their feet.

Maybe under a baby gym they will reach up or out for something.

Nesting:

Use a rolled up towel to tilt his pelvis and flex (bent) his hips and knees when he is on his back

This will encourage and help him to reach for his toes and build his tummy muscle strength.

Using nests  gives baby boundaries so they feel safer and have something this push against, this gives them more sensory feedback so they are learning more about their body.

You can play with baby bringing their feet together and clapping them, bringing hands to feet and rocking side to side.

Opposite hand to foot to help them clap like this or pull of a sock – all helps with them connecting the two sides of their brain and learning about their bodies.

Tummy Time: Really rolling time – babies are only ready for tummy time once they can roll onto their tummy!! Once they can do this, they can lift their head so will enjoy being on their tummy to play.

If your child has additional needs then you may wish to use tummy time as therapy and you can help your little one be happier for longer on his tummy by using a rolled up towel under his chest and by applying a little pressure to his bottom to help him shift his weight back.

Movement – with baby in your arms bounce them up and down, swing them forward and back, side to side. Spin them around. Stop and see their reaction. Give them chance to tell you what they think and make vocalisations to say go (ready steady…). They will start to anticipate and shout for go. Movement is the best way we have to communicate directly with the brain – when kids are moving they are learning.

Tactile play– offer pine cones, wrapping paper, space blankets, crisp packets to rustle, sponges to squeeze etc.

Vision and hearing- try a torch in the dark and see if your baby will track the light with their eyes. Encourage them to follow visual toys that are quiet so they are using vision and not relying on their hearing. Then you can bring on the noisy toys and start and stop, building anticipation and see if they can reach for the toy to turn it on. The beginnings of cause and effect.

If you are worried that your child has significant difficulties processing sensory information then you can ask your GP to refer you to children’s Occupational Therapist.

If you are worried your child has a developmental delay again contact your GP, or call local Physio team.

Some other posts in the pipeline:

– The low down on baby slings

– Some Physio tried and tested toys and equipment I would recommend.

To finish, an apology for the lack of posts this month – it has been a busy one. I will do better in July!

Sensory Integration, our 7 senses, Sensory Processing through typical development and how it is affected by Cerebral Palsy

7 Senses?

We have the five senses we all know about: sight, hearing, smell, taste and touch 7 senses.png(tactile). Then we also have our sense of proprioception (our body awareness – where our body is in space) and vestibular (movement).  We’re going to look at tactile, proprioception and vestibular in more detail. These are very important in child development; as they get integrated (this refers to the way the receptors on our skin, in our eyes and so on receive the information, and how our brains process it, and therefore how we react to it).

 

Our sense of proprioception is really important. When we’re born – we tend to be all flexed up in a ball, and this physiological flexion gives us proprioception: i.e. it tells us where we are and is reassuring, along with touch from Mum or Dad, being cuddled. We can see that we need this as, if we lay a babyProp on the floor with nothing touching them, they startle – as they don’t know where their body ends and the world begins.  We get our proprioception from the receptors in our joints and our muscles. They send signals up to the brain and tell you where your limbs are. So if you clench your fist or wiggle your fingers, you can feel your hand; whereas if you just let your hand lie still, it’s more difficult to feel exactly where the hand is. Proprioception relies on movement of the joints and stretch or activation of the muscles.  As you develop; start to hold your head upright in the midline, roll over, push through your arms on your tummy, sit up and balance using the muscles in your trunk, stand and put pressure through your legs and eventually start to walk, you are building your body map, using the pathways between the proprioceptors and the brain.

 

Alongside all of this we receive tactile information through receptors in the skin. The information is carried along two different tracts or pathways up the spinal cord and into tactilethe brain: light touch along one tract, and deeper pressure along the other.  All of this tactile information that we receive as babies (from being stroked, the feeling of our clothes, the pressure of the floor against our back or tummy or side) adds to the body schema and helps us to know where we are in space. That deep, firm touch is similar to proprioception; it’s quite calming, organising, it helps us to know where we are and feel safe. If you’re getting worked up and you clench your fists and bite down – or have a hug – it can help to calm and relax you. The light, more tickly type of touch can be a bit arousing and exciting; it can make you shiver or giggle. It goes up the same tract as pain and it’s more exciting than calming.

 

Your sense of vestibular or movement is affected by where your head is in relation to your body. Your eyes feed into the vestibular system in your inner ear.  The system has two different types of receptors: firstly, there are sponge-like, linear structures (called otoliths), which tell you whether you’re moving up or down, or forwards or back; vestsecondly there are the semi-circular canals, like little cups of water, which tell you whether you are tipping or spinning. The vestibular system is very important in terms of your balance.  As different types of touch can be either calming or exciting, so too can input to the vestibular system. Linear, forwards-and-backwards movements that stimulate the sponge-like receptors can be calming and organising and help you to focus. If the semi-circular canals are stimulated, this is arousing – it’s telling you that you’re tipping or falling and you need to correct vestibu.jpgyourself. This is why riding on a rollercoaster or spinning round and round can make you feel giddy and excited (or dizzy or nauseous!). If you’re feeling sleepy, tipping your head from side to side or turning upside down can be a good way to wake yourself up.

 

Think of a toddler, toddling around. Generally they do lots of climbing, jumping off things, they’re running in the park, they’re on the swings, the roundabout… They’re constantly exploring their body, their muscles and joints are working so they’re getting lots of proprioception (so that’s calming and organising). Your receptors are being stimulated – you’re touching the grass, the climbing frame, the sofa, the carpet, the floor, your whole body is getting different types of touch, you’re rolling on the ground. SI.jpgAlso you’re stimulating the movement sensors in combination with these things. You might be spinning around, you might be climbing up and down things, you’re doing a good mixture of things that are exciting to the system, along with things that dampen down that excitement. That’s what’s called regulation – it keeps you in a good calm, alert state and means that you can still focus on the world around you. You can still listen if your mum and dad are calling you, you can still think and plan what you’re going to do so that you can stay relatively safe. This is the calm, alert state of arousal that you’re in when you’re not so sleepy or under-aroused that you’re not aware of things around you – so that you might trip over a kerb, you might not attend to a noise like somebody calling your name, you might not see someone waving at you – and equally you’re not over­-aroused, so you’re not too excited or too giddy or too upset that you can’t calm yourself down in order to be able to sit still in the classroom, to do good listening, to learn, to function.  The calm, alert state – somewhere in the middle – allows you to listen to the things you need to listen to, and zone out the things you don’t need to attend to.

This is called sensory integration.  As children develop, move around and explore, their senses naturally become integrated. All the information from all the receptors goes up the pathways or tracts into the brain and is processed, and anything that definitely needs to be flagged to remember for next time – such as a green or red light when you’re crossing the road, or a car coming towards you, or your mum saying “Stop!” or “That’s really hot!” – those kind of flags get an immediate response because you’ve learnt that over time. Equally things that you’ve realised you can zone out – things that happen all the time such as doors closing, noises in the night, noises in the classroom while you’re paying attention to the teacher you habituate (get used) to them and you don’t listen to them. That’s if you have good, typical sensory processing.

So What is Different if a child has Cerebral, Palsy?

If you have a child with cerebral palsy, whose independent physical mobility is restricted – maybe their movement patterns are not typical, they might move their arms and legs more in one direction than another, or use certain muscles more than others toCP

activate movement, maybe certain parts of their body might get more touch than other parts – they might have missed the tummy time stage for example, or the rolling stage (rolling over and over is really good for body awareness, for learning where your body ends and the floor begins). They might have missed the crawling stage, when you’re getting weight bearing through the shoulders, elbows and wrists, through the knees and up into the hips, it’s activating the joints, it’s CPPtelling your body where it is in space, if you miss that stage then you’re going to miss out on that proprioception or body awareness. Your body schema (body map) will not be typical, and your perception (e.g. of where the midline is) will be altered. Remember the proprioceptors are the calming, organising inputs that help you to focus and organise and dampen down any excitatory inputs. Your touch receptors – if your hand is closed most of the time you are not going to have experienced lots of different types of touch on your palm.

Your movement sensors… If your head hasn’t been in the upright position in lots of different ways – when you’re lying on your tummy and lifting your head for the first time, when you’re learning your head control, and then when you’re starting to balance in sitting and then standing, using a mixture of your flexors and extensors (the muscles on the front and back of your body), getting that co-contraction – all of these things feed into your balance and your vestibular system. If you haven’t had that, or maybe experienced this in an asymmetrical pattern, then your vestibular system will have an altered perception of what is upright.

How quickly your body responds to you falling sideways, for example, will depend on how well integrated the receptors of that system are, whether the receptors are receiving the information at all, whether enough input has been put into the system for the receptors to have sent it up to the brain, or whether they are over-sending so you’re constantly responding to the information because maybe your muscle tone is high and it’s sending signals all the time.

So not surprisingly, children with cerebral palsy have some difficulty with their sensory integration, and this can affect therefore their calm alert state – so their ability to regulate their emotional state, to calm down when they’re upset, to regulate how excited they get and how they respond to that excitement, to be able to continue with a task if a distraction has caught their eye or some auditory information has come in, to be able to think to themselves “I don’t need to attend to that, I’m going to carry on with what I’m doing”.

You might see that a child can perform a particular task in one situation – when they’ve been doing something prior to that maybe – but then in another situation they can’t do it, and you think, “I know they can do this, but they’re not performing right now.” It may be that the situation that they’re in, the environment that they’re in or the preparation they’ve had affects their performance and their function. This can have a big impact on their learning in school, if one environment they learn or perform well in, whereas other environments they maybe don’t.

Part of our role as Physiotherapists and parents and carers is to ensure that no matter what your child’s physical ability they get to experience a wide range of play activities, positions and movements to build their library of sensory experiences and organise the sensory input so they can attend and respond to stimuli and adapt in new environments, to be more effective learners and players and ultimately successful adults.

How Babies develop the Stability and Mobility needed to Walk and where Babywalkers fit in

I get asked a lot about baby walkers/ bouncers – are they good for children? Do they help them to walk?

No, and No. I’ll explain why we don’t recommend the use of them (However I do know as a parent, that often a walker or jumparoo can be the only place your baby will go in happily to give you 5 minutes to go to the toilet or finish cooking dinner – if you have one and need to use it then use it sparingly and with the following information in mind ):

Babies develop in stages, and each stage lays the foundation for the next. As a very young baby, you start to develop some core balance between the muscles on the front and back of your trunk, which gives you some stability and helps you to hold your head up. From there, you start to be able to use your arms, separating them from your body – for example pushing up on your arms when lying on your tummy, lifting your head up, using the strength in your back to shift your centre of gravity from your heavy head and down towards your bottom. When you’re lying on your back you start to realise you can move your arms away from your body to reach up for toys, to grab your toes and bring them to your mouth – along with everything else you can get your hands on! This is working your tummy muscles and muscles at front of your shoulders. bringing those feet up high and reaching for them starts to stretch out the muscles that are in a shortened position at birth, for example, your hamstrings (muscles at the back of the hip and knee).

All the work at each stage develops the muscle control and movement control needed for the next stage.  So after grabbing your feet on your back, and then pushing up on straight arms on your tummy, you start to learn to roll over, combining some of these new skills: pulling into flexion to make your base a bit unstable so that you can roll from your back to your side, using your arms (that have been practising reaching up for toys) to reach over, and then push up with that new-found extension, straightening your back and lifting your head to be able to roll onto your tummy. So rolling takes a combination of the flexion you learned when lying on your back and the extension you practised when lying on your tummy. You need the stability and trunk control that you learned when you were being held, and the head control – being able to lift your head by tucking your chin when you’re on your back and by extending your neck when you’re on your tummy. All of this balance of control helps you first with rolling, and then with your next big gross motor developmental milestone- sitting.

When you’re sitting, the stability you have developed around your shoulders, from floor play on your back and tummy, together with the strength and balance – being able to switch between using muscles on the front of the trunk (the flexors) and the back of the trunk (the extensors), with your head control – all work together to keep you upright. All the time you’re practising your sitting you’re still perfecting your rolling, your grasp and release, arm stability… Playing on your back and your tummy, exploring toys in your hand and mouth, pulling your own socks off – all these play positions strengthen the early foundations and build the layers for the next stages of development.

When children first learn to sit they generally only grab for toys within their base of support, and slowly they start to develop the strength and confidence to push on one arm and lean gradually further out. This might take them onto their hands and knees or to side sitting (where the legs are swept to one side and you’re leaning on one arm). From there you might go onto hands and knees, perhaps to grab a toy that was just out of reach. Now we’re starting to build in more of a 3D strength (as opposed to the 2D strength of being on your back or your tummy) – we have rotation, we have lengthening – one side of the trunk while the other side is short… This all helps to build that support around the trunk that we need. By supporting yourself on your hands and arms, you gain further stability around shoulder girdles which supports better fine motor control (use of hands), pushing through the palm helps the intrinsic muscles in your hands develop.

When you’re in a crawling position you might rock forwards and back, testing out the stability in your shoulder and hip girdles, and increasing the flexibility/mobility around pelvis – you may then go back into sitting and realise that this tilting pelvis gives you a bit more reach. Reaching forward from sitting position also helps to further lengthen your hamstrings, ready for standing and walking.

Once you are crawling, you start to learn how to move your legs reciprocally, i.e. independently of each other – one leg stays back in a more extended position to support you, the other steps forward in a more flexed position, and then they swap. From crawling you start to experiment by coming up onto your knees, maybe reaching up and climbing onto the sofa. Now you really need the stability around the pelvis you have been working on now as well as the strength in your arms to support yourself as you start to rise from the floor!  You also need the reciprocal movement that your legs have been practising in crawling to bring one leg through and push up to standing.

From standing, you use all the stability and mobility you have gained so far to feel safe and secure so you feel relaxed and comfortable playing up at the next level. No need to stiffen your legs or point your toes to feel more stable.

Your playing and shifting your weight from one leg to the other as you reach to play with toys on the left and toys to the right, then you realise you can step sideways along the sofa to reach even further, using your strong arms to support yourself when your need to. This activates the muscles at the side of the bottom and hip, which are really important to keep your pelvis level and steady when you’re walking.  From there you might start to take risks and ‘gapping’ between pieces of furniture, squatting down to reach for toys and rising again. Building that stability and confidence. and from there you’ll learn to walk.

Then one day you find yourself standing in the middle of the floor, no table or sofa around you and you walk, like you have been doing it all along!

So, where do baby walkers/ bouncers fit in with this? The answer is they don’t!

In a walker – you are sitting in a sling and bouncing or propelling yourself forward on your toes in a bunny hopping style. They take time away from floor play and moving between these important developmental milestones in an order where different positions and activities support both, the skills that started to develop earlier and those still to come. Helping children to lengthen the muscles they need longer for when they are up and about and to build stability required to master stages and embark on new adventures in different positions.

Baby walkers/ bouncers take you up into standing well before children are ready to be there – so children compensate by pointing their toes to gain stability they don’t yet have and using both legs together to propel themselves forward as they haven’t learnt to step reciprocally (one foot at a time yet).

When your child is ready to walk – almost there: they are cruising with furniture, walking along the cupboards in the kitchen and taking a few steps between furniture (gapping) then a push along walker van be a great piece of equipment for them to use.

How far is too far for my child to walk?

Can you help make my child walk farther and stop them complaining of being tired when we are walking?

For children who are typically developing (without a disability), the answer to the question is most often yes – often parents worrying about this, need someone to check that there is not a physical problem so they are reassured and have the confidence then to encourage their child. If a child gets tired after 5/10 minutes so we carry them, or put them in the pram, they will not build up their stamina and endurance, so they will always feel tired after walking 5/10 minutes.

I don’t know if it is just my children, but from being very young, my boys would let me know when they were not 100% content! Are they screaming because they are in mortal pain – turns out no, just woken up and need feeding 2 minutes ago; or really, really don’t like having their bottoms changed! Then they got older and when they screamed because I have mixed the bolognaise in with the pasta – I thought, is this reasonable or unreasonable??? I wondered if maybe it was harder for them to manage mixed consistencies, so gave them a new plate of food – with the sauce separate from the pasta – Because I didn’t know, I erred on the side of caution.

However, when it came to them walking – being a Physio Mum – I was able to confidently reassure them that their legs were not going to drop off if they walked for a few more minutes. When my youngest was born my eldest was 2 years old, and we didn’t have a pram (I carried the little one in a baby sling). My eldest either walked or he rode his balance bike, which he had mastered by 2 ½ (and then his pedal bike from 3 ½). Now 4 and 6 years old they will walk 3/4 miles with us exploring in the forest, and cycle confidently alongside us on our bikes – and yes they still complain sometimes, and we give them energy boosting apples and wear our super explorer shoes to keep them going!

However, I know that for many parents knowing how far, is too far for their child to walk is difficult. So when their child starts screaming to be picked up, or asks to go in the pram – they err on the side of caution.

I can reassure you, for typically developing children, once they can walk, they can’t really walk too much. If you leave the pram behind they will soon stop asking to go in it, if you say they are too big to carry- and stick to that, they won’t ask to be carried. If they are tired – sit and take a break, grab a snack, have a drink, do some energy boosting jumps, then, off you go again.

Reassure them that we all get a bit tired sometimes and that’s OK; they have very strong legs and are fit and healthy so can make it… to the shops, to school, home and beyond!

If you are worried about your child’s physical abilities, or how they walk then you can go to your GP to check out your concerns, and ask for a referral to Physio if they can’t allay your fears.


NHS have guidelines about physical activity for under 5’s and over 5’s:

Toddlers

Children who can walk on their own should be physically active every day for at least 180 minutes (three hours). This should be spread throughout the day, indoors or outside. The 180 minutes can include light activity such as standing up, moving around, rolling and playing, as well as more energetic activity like skipping, hopping, running and jumping. Active play, such as using a climbing frame, riding a bike, playing in water, chasing games and ball games, is the best way for this age group to get moving.

Guidelines for 5- to 18-year-olds 

To maintain a basic level of health, children and young people aged 5 to 18 need to do:

We will talk more about these recommendations and how we help children with physical disabilities access enough physical activity to stay healthy or improve their health.