Starfish Therapies

April 8, 2016

Hip Dysplasia

Filed under: Developmental Milestones — Starfish Therapies @ 7:41 pm
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As parents of babies or young children you may have heard the term hip dysplasia or you may remember your pediatrician moving your little ones hips around at all those check-ups during the first year.  They are feeling and listening for clicks or clunks which, when felt may indicate hip dysplasia.

Hip dysplasia is the term used to describe a hip joint that is not properly formed so that either the hip can be dislocated and relocated with passive movement or is already in a dislocated position. The term developmental dysplasia of the hip (DDH) is used when the condition is present in a newborn or develops sometime around birth, usually in the first year of life. As physical therapists, we know that most of the time DDH is present at birth and can be attributed to the baby’s position in the womb. Specifically, the breech position is found to be a cause for DDH present at birth. While the exact cause of DDH in other cases is not known, there is an increased likelihood with a positive family history as well as in the female gender, with girls being 4-5 times more likely to have hip dysplasia than boys. However, we also know that DDH can develop over time in otherwise healthy hip joints or can further the amount of hip dysplasia in a mild case that is maybe yet to be diagnosed. Read the tips below so will know the signs of hip dysplasia as well as how to prevent it from developing or worsening by understanding how to position baby with swaddles, carriers, etc.

1. Signs of hip dysplasia that you can take note of and tell your doctor about:

  • Asymmetry of skin folds: when your baby is lying on his or her tummy, the gluteal and thigh folds should be symmetrical at the same height.
  • Loud, audible clicking or clunking felt during diaper changes
  • Limited range of motion available at one or both hips

2. Swaddling

  • Swaddles should be loose around the hips and thighs to allow for baby’s natural hip position (flexed and externally rotated). Baby should have free movement from the waist down.
  • Swaddles should not hold baby’s hips extended or close together.

3. Baby carriers

  • Baby carriers should support baby underneath the buttock and thighs and allow the legs to spread apart with flexion at the hips.
  • Baby’s hips are more at risk when they are allowed to dangle straight down or are held close together in a sling type carrier.

For more information as well as images that demonstrate proper hip positioning during swaddling, use of baby carriers and car seats, visit the International Hip Dysplasia Institute website here. If you have questions about specific products out there, let us know!

March 10, 2016

Priming the Muscles

 I was giving a presentation the other night on Strength Training for Children with Developmental Coordination Disorder and it led to an interesting conversation with the attendees.  It was actually a really great conversation because it was a collaboration amongst a mix of pediatric and adult therapists.

We were discussing children who have hypotonia (low muscle tone), and how they have a harder time turning their muscles on and keeping them on.  Strengthening helps them to be more efficient with turning their muscles on but their low tone never goes away.  It came up that they often become tired easily, and this can show up in school, because they have to focus on their posture (staying in their seat) as well as whatever activity they are doing.

One therapist shared a great story about a child she was working with who was struggling with a specific test that he had to take every week at school because he was focusing on staying in his chair, writing on his paper, and answering the questions in a timed fashion.  His scores were not very good.  They came up with a strategy (that the school approved) for him to do a modified plank on his knees before the test.  Immediately his test scores started to improve because he was priming his muscles to turn on during the activity.  It was easier for him to keep himself in his chair because he reminded his muscles that they need to work.  A few weeks later, the teacher reported that all of the kids wanted to do this and started doing the modified plank with him (so now he doesn’t look any different than his peers).  I thought this was a great example of how to support education through physical activity.

I know myself, when I do a 10 minute yoga routine I put together, my posture is better (without me thinking about it) for the rest of the day.  This is because I have reminded my posture muscles that they are supposed to be working.

So how can we use this?  For kids that have lower muscle tone, we might want to consider giving them a physical activity at the start of their day that can prime their muscles.  This could be modified plank or bear walking or some simple yoga poses.  Or if not at the beginning of their day maybe before a test at school or before they start their homework or before PE or other physical activity.

I know families who have kids with low tone who have been able to move on from physical therapy and get their kids involved in martial arts, swimming, or gymnastics (to name a few).  This is great because these activities help with whole body muscle activation as well as provide a social way to keep active.

I’d love to hear other ideas you have for ‘priming the muscles’!

February 3, 2015

Understanding Terminology: Ankle and Knee

Filed under: Developmental Milestones — Starfish Therapies @ 5:17 am
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legsOften in physical therapy, we use certain terminology to describe the position or alignment of the legs at rest or during activity.  You have probably seen these terms in your child’s evaluations or progress reports and they probably didn’t make much sense.  Even if your therapist explained the meaning to you, it still might not have made much sense. Hopefully this article can help clear up the meaning of these strange words and what they indicate.


Kids Advnetures
Pronation – This is a term used to describe the sum of three different motions that together cause the heel to slant inward, the arch to collapse toward the floor, and the foot to turn outward during standing and walking.  A certain amount of pronation is normal during the walking cycle. However, if there is an excessive amount present it can lead to stress on ligaments and muscles and can cause other alignment issues throughout the rest of the leg over time.  Excessive pronation is most common in individuals with low muscle tone but can also occur individuals with high muscle tone.
supinationSupination – This term is used to describe the sum of three different motions that together cause the foot to point downward and turn inward. This foot position is common in individuals with increased muscle tone and in certain diagnoses such as Cerebral Palsy.
Pronation and supination can be present during standing or during isolated times of the walking cycle.
Genu Valgum (knock knees)- This term describes knees that are touching or close to touching while the lower leg is bent outwards and the ankles are separated more than normal (see picture below). This alignment is a normal part of development around 2-3 years of age and in most cases will naturally straighten out by 5-6 years of age. However, it may persist when other impairments are involved.  It is often seen in combination with ankle/foot pronation described above. Very severe cases may require surgical intervention.
Genu Varum (bow legs) – This term describes the opposite of genu valgum.  The knees are separated while the ankles come closer to the midline of the body (see picture below).  This alignment is normal in infants and during the first year but should decrease as weight is introduced through the legs with standing and walking.
From infancy to childhood, a typically developing child should progress from genu varum during the first year of life to a relatively straight position with the onset of walking and then into genu valgum around 2-3 years.  The legs should then again realign themselves into a relatively straight position by around 5-6 years.  Females will tend to have slightly more genu valgum than males due to the greater width of the pelvis.
genu valgum and varum
From left to right, the pictures represent genu valgum (knock knees), normal alignment, and genu varum (bow legs).

October 17, 2014

Posture Tips for Parents and Caregivers

Filed under: Developmental Milestones — Starfish Therapies @ 2:00 pm
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wheelbarrow kiddo

We thought we would take a moment to share some posture tips for parents and caregivers to help prevent injury or overuse during day-to-day activities when caring for a young child. For additional information and a video demonstration on some of these techniques, please visit this link.

1. Lifting your child: Whether lifting your child off of the floor or out of their crib, you want to make sure you avoid lifting with your back and instead lift with you legs.

  • When lifting a child from the floor, the easiest way to do so would be to place one foot in front of the other and then bend your hips and knees until you are in a kneeling position on one knee (half kneel). Make sure you keep your back straight! Once in the kneeling position, lift your child up with both hands and bring them close to your body. From there, hold your abdominal muscles tight, and use your legs to bring yourself back into a standing position.
  • When lifting a child from their crib, you want to lower the rail as low as it will go. You’ll want to bend at your hips and knees to perform a mini squat, almost as if you were pretending to sit down in a chair. Make sure your back stays straight! Then, pick up your child with both hands and bring them close to your body. Then straighten your hips and knees and return to a standing position while keeping your abs tight. To place them in their crib, you’ll want to use the same ‘mini squat’ technique.

2. Pushing a stroller: When pushing a stroller, you want to avoid letting the stroller get too far ahead of you, as that will cause you to hunch forwards at your shoulders and upper back. Try and keep your back straight and use your entire body to generate the momentum needed to push the stroller forwards, not just your arms!

3. Carrying or holding your child: Try and avoid carrying your child with one arm and balanced on your hip. If this position is an absolute necessity, make sure you switch sides. This position causes certain muscles to lengthen on one side of the body, while other muscles on the opposite side of the body tighten, putting you at risk for postural asymmetries and potentially leading to pain.

March 16, 2014

A Few Examples of the Importance of Postural Control

Filed under: Developmental Milestones — Starfish Therapies @ 9:09 pm
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platform swing

JR is 5-year-old boy and can’t sit in a chair or on the floor for more than 1 or 2 minutes at a time. He’s in constant motion and if he focuses on sitting still he can’t listen or pay attention to anything else. When in a chair he’s sitting on his feet, standing up and down, or moving in his chair so much it’s actually moving the chair itself. When on the floor he is either bumping into his friends or rolling around.

KC is a 5-year-old little girl that can sit in a chair or on the floor, although always seems extremely tired. When at the table she is slouched forward in her chair, or leaning forward and resting her head in her hands or laying her head on the table. When seated on the floor you may see her using a “w” sit or sitting with her legs forward but having to support herself with her hands in back of her to remain in this position.

Both of these kids seem to be at the opposite ends of the spectrum in how they act both seated in a chair and when on the floor, but in actuality could be both experiencing the same postural control issues. They each have their own way to deal with weakened postural control, but may also have other underlying issues that influence the way they act in addition. Postural control allows us better control of our distal extremities (arms and legs) and can also assist in helping us attend to someone or something better when we need to.

In order to compensate for his weakened postural control JR moves excessively. The movement helps him in remaining upright, but can lead to increased distractibility and difficulty in attention. This movement keeps him alert and at an increased arousal level. KC allows her postural control to take over for her instead and she is notably experiencing a lower arousal level when seated. She allows her body to sink back into things and depends on her upper extremities for support in a lot of cases to keep her upright. This lower arousal can lead to inattention as well at times, and she can tune out others around her.

Postural control is extremely important not only in a child’s attention and focus, but also in fine motor. In both JR and KC’s cases, their fine motor abilities can be affected depending on how they are able to sit down. Good postural control is also important in our balance and in helping us navigate our different environments appropriately and safely. There are many ways to work on postural control that are fun and exciting for kids. Here are some to check out.

Great Postural Control Activities:

Kids Yoga



Yoga ball exercises

Animal Walks


February 12, 2014

Straighten Up: Helpful Hints for Posture at School


It’s at least halfway through the school year and a great time to think about posture!  More often than not, children tend to pay little attention to their posture while focusing on something else such as school work, television, or video games. Most commonly, you will see them slouching forward, leaning to one side, propping on one or both elbows, propping their head in their hands or even lying their head on the desk while writing or drawing. They may appear unaware of this  when corrected because unlike adults, most kids do not experience back and neck pain related to poor posture. It is also difficult to help them why good posture matters in order to prevent habits that could potentially cause problems later in life.

Tips to Improve Your Child’s Posture:

  • Lead by Example: Draw attention to your own posture and show your child what sitting up tall looks like.
  • Mirror: Using a mirror is a great way to show your child what their posture looks like or what it should look like.  Specifically, having them stand sideways can making slouching more apparent.
  • Chair: The chair your child uses can make a huge difference in their posture.  It is important for their feet to rest flat on the floor and that their knees are bent roughly 90 degrees.  It is also important to look at the length of the seat.  If the back of the chair does not touch your child’s back while their feet are on the ground place a pillow in between the space for support.  If the only chair you have to use is so high that your child’s feet are dangling in the air, place a stool or wooden block underneath for their feet to rest flat on.
  • Desk:  The height of the desk is also important.  It should hit slightly above your child’s belly button in the middle of their trunk.  If it is too low, your child will slouch forward to reach their work.  If it is too high, your child will have to elevate their shoulders towards their ears raise their arms up to reach what they are doing and will therefore, be overusing certain neck and shoulder muscles.  If your child is too low at the table, you can place pillows or cushions under their bottom but then again may need to place something under their feet so they do not hang.
  • Set Limits:  It is important to set time limits on computer/television/video game sessions.  Try limiting bursts of these activites to 20 minutes at a time.  After 20 minutes, encourage your child to get up and move around for a while.

If you have been working on your child’s posture and do not see improvement or if your child complains of pain or seems unable to sit still for periods of time, they may have some underlying muscle tightness or weakness that makes a good, neutral posture very difficult to achieve and they may need some targeted strengthening or stretching.

How do you work on your kiddo(s)’ posture?

October 31, 2012

Some Thoughts on Perplexus

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We have a few of the Perplexus models here because I think they are really cool. For those of you who have never seen them they are a clear globe with a complex track inside that is broken up by colors and you need to keep a small ball on the track from the start to the end.  It is a great way to work on motor planning, visual motor skills, and bilateral coordination.

I recently decided to try the ‘rookie’ with my kiddo who has spastic quadriplegia CP.  I wasn’t sure how it would go based on his physical challenges but I knew intellectually he was bright enough to know what to do.  It was really interesting to watch him try to work it out.  First I demonstrated it to him and he talked me through which way to turn the globe so that the ball stays on the track.  He was able to verbally instruct me as well as point to the direction of movement that I needed to move the globe.  Clearly he understood the concept of it.

Next I gave it to him.  He concentrated so hard on it but had a really hard time moving the globe within his hands.  It was easier for him to keep his hands stable on the globe and try to twist it.  When he did this the ball frequently fell off the track.  I began working with him on how to turn the globe within his hands.  I used some hand over hand and step by step verbal cues and he began to get the hang of it.  He needed to use a lot of extra stabilization such as with his chest and his chin while he attempted to move his hands without the globe moving with them.  He also did a great job of maintaining an upright posture while doing this activity.  He has a tendency to slouch when sitting in a chair and performing activities with his hands so it was great to see that this game allowed him to maintain his postural stability much better than normal.

I would say with a kiddo like this the motor planning required for the bilateral coordination of his hands and then integrating the visual is what it really works on.  Whats great is that because it is broken up by color you can create goals such as get to the red track and then get to the purple track, so that they don’t get frustrated when the ball falls off the track.  When I did step in and help a bit I had him continue to direct how we should turn it so that he was able to continue his intellectual and visual problem solving.

How have you used the Perplexus?

October 22, 2012

Internal Rotation and Walking

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Okay, I tried to get creative with the title and my creative juices just are not flowing today!

This post looks at internal rotation and walking (as if you couldn’t figure that).  We have several kiddos that we see that use excessive internal rotation when walking (toes pointing in) and many times parents ask how we can correct that.  What we have found for a lot of these kiddos is that while they do have internal rotation, it is not as excessive as it may appear when they are walking.  Many kids will use compensatory movements while walking for a variety of reasons.  Some of the things we have found that contribute to the appearance of excessive internal rotation are the use of circumduction (swinging the leg around causing an internal rotation like movement), pelvic instability (so because of weak hip abductors they can’t maintain a level pelvis when they take a step and the side of the pelvis that is taking the step will drop down causing the leg to look like it is going further into the center), and initiating swing from the pelvis (so instead of a straight plane step through they are swinging their leg through using the whole pelvis).

We have found that if we can provide stability at the pelvis, or even slow the kiddos down while walking some of these compensations will decrease.  When the compensations decrease, you will still have the internal rotation that is already present but you won’t have the illusion of more rotation because they will be using more deliberate actions.

We have also found that when kiddos get AFO’s or other orthotics it will also increase the appearance of internal rotation for some of the same reasons.  I’ve mentioned before that when you change one thing you will see changes in other areas.  So when a child gets a new foot brace, they may be trying to figure out how to use it and it can alter their swing phase of walking and bring out compensations.

I’m not sure how well you can see it in the video but in the first part the child moves fast and uses their body to lean into the movement and they have poor pelvic stability as well as increased circumduction/use of their pelvis to initiate swing phase.  When we changed the walker and gave them some hip stability, as well as used leg cuffs to not let the leg drop into the middle (that can happen when the pelvis drops) the appearance of internal rotation decreases.  You can see more deliberate stepping and they aren’t able to use their momentum to keep them moving.

Using a walker isn’t for all kids but for this particular child it was one way to decreased the excessive internal rotation that was happening.

We did not try to correct for his actual internal rotation because of his age and the fact that bony changes have occurred altering the alignment of his femur.  By trying to use strapping to make his toes point forward we would have put his hips at risk.

What have you used to help kiddos that walk with this similar pattern?

October 12, 2012

Postural Control – How the Systems Work Together

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Postural control is a term used to describe the way our central nervous system regulates sensory information from other systems in order to produce adequate motor output or muscle activity to maintain a controlled, upright posture. The visual, vestibular, and somatosensory systems are the main sensory systems involved in postural control.

The visual system contributes to postural control by delivering information from the retina to different areas in the brain that allow for object identification and movement control.  Therefore, if your child has a visual impairment, it may be affecting their ability to control their posture and balance especially during movement.

The vestibular system, which consists of organs located in the inner ear, contributes by interpreting changes in movement, direction and velocity or speed of movements. This information is sent to the brain stem, which then creates a response that allows your postural muscles to activate and increases your body awareness.  The vestibular system can be affected in children with various syndromes and disabilities.

The somatosensory system contributes by relaying information about body position to the brain, allowing it to activate the appropriate motor response or movement.  Specific receptors or gauges called proprioceptors are located in our muscles, tendons, and joints.  These are the receptors that are able to tell our brain whether our knee is bent or straight, whether we are bearing weight or not, and which muscles are contracting and which are relaxing at any moment. Inadequate somatosensation will affect postural control as well.

So you can see that all three of these systems play an important role in maintaining postural control and balance.  To ensure proper postural control, the sensory information from these three systems must be regulated by the central nervous system in order to produce an appropriate motor response.  So what does proper postural control look like? This is when an individual is able to engage in various static and dynamic activities, such as sitting, standing, kneeling, quadruped, crawling, walking, and running with the ability to contract the appropriate muscles required for a controlled midline posture, as well as the ability to make small adjustments in response to changes in position and movement, without the use of compensatory motions. If even one of the mentioned systems is not working the way it is supposed to it can affect postural control and balance.  However, when one system is affected the other two can be trained to compensate.  If more than one system is affected in combination with central nervous system involvement postural control will be more greatly affected.  Talk with your therapist for ways to assist your child achieve improved postural control.

October 3, 2012

Using the Ball vs the Platform Swing for Balance Reactions


As a therapist, we use the therapy ball a lot with our kids.  It helps them to work on balance reactions and postural control as well as provides vestibular input in a variety of directions.  The kids love it because usually we sing to them and bounce them and they may even forget they are working.  There are a few things to consider when using the ball though.  Generally you are holding onto the child in some way so they are being provided stability (most likely at the pelvis) which allows them to only concentrate on activating their core without having to figure out how to counterbalance at the pelvis.  In addition, usually kids are sitting with their feet hanging down in front of them so they are able to pull in their leg muscles to assist with activating their trunk muscles by using the overflow.  If they over recruit their muscles, they can generally push against your hands to give themselves extra support.  Finally (although I am sure there a quite a few more points that I didn’t bring up), if you are holding them at their pelvis or even their trunk, I can almost guarantee that you are helping them correct their posture in some way, shape or form.

Another alternative to use in conjunction or to switch it up is to utilize a platform swing.  You can have the child sit in ring sitting, tailor sitting, side sitting, etc in front of you and then you can move the swing forward, backwards, sideways or even diagonal (similar to the directions you can move the ball) and see how the child reacts.  This method is great because it can let the child practice sitting ‘independently’ (although with you close by) so they can practice using their pelvis to counterbalance their trunk reactions.  For example, if the swing moves to the right, the child needs to stop the movement towards the right by pushing their left hip down into the surface and use their trunk muscles to shift them back to midline.  In the beginning, especially with the side to side motions, kids have a hard time preparing their body for the movement and need help to not topple over.  I usually start with slow, small movements until they begin to get the hang of it and then I will increase the speed or the size of the movement.  By having their legs crossed in front of them they also have to work harder to isolate their trunk extensors and other trunk muscles.  If you have a kiddo with higher tone, they will attempt to push their legs into extension while trying to stabilize.

Now I know not everyone has access to a platform swing so what other tools or tricks have you used to work on balance reactions on a dynamic surface, without giving the kiddo stabilization?

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