Category Archives: Pediatric

Child Standing Training

Training of child to stand is one of the main goal that most of the parent want to achieve. Some parents believe that after the child stand, child can already do other physical skills. Sometimes it is true but not all the time. Sometimes child that can stand already will be having problem in walking on stairs. Here are the facts about standing training.

Early Standing

Trust Issues in Physical Therapy

Patients can be uncooperative when they do not trust the safety of Physical Therapy Intervention. I have a 2 year old patient that it took awhile before he can bear weight on his legs when I hold his hands. But he can bear weight on legs while he is holding on the furniture. I let him stand and cruise on the furniture while little by little I applied a little support on hands to let go of furniture. He is now able to step with support on both hands.
There are also cases that the patients can walk with support of the PT but not cooperative with their parent. Sometimes patient can trust PT more than their parent because we see them a lot and do physical activities with them. When the parent start to do it they are not used to it so they do not trust them very much.
Avoid fall during standing or walking activities when the patient is too apprehensive. It can lower their trust to their physical abilities.

Developmental Mileage

Although babies develop differently, majority of the babies develops just like the following.

0 to1 month: Head aligned when held vertically. Rotates head and move legs while lying on stomach. When the head rotates to the right, the right arms and legs extend. Rolls to back when placed in side lying position. Arms and legs move while lying on their back.
 2 to 3 months: Head aligned and stiffens legs when bounced three times.  Raised head and chest then bear weight on arms while lying on stomach. Bear weight on legs for three seconds and show stepping reflex when placed in standing position. When pulled up to sitting the head maintain its alignment. Kick legs simultaneously while lying on their back.
4 to 5 months: Head and body aligned when supported around the waist. Reach toys up on eye level while lying on stomach. Bear weight on legs when supported three seconds. While lying on back, grabs the feet, and pull self to sitting when assisted. From lying on back, they roll to the side.
6 to 7 months: Maintain sitting while playing toy for about a minute. Bear weight on hands and crawl about three feet while lying on stomach. Rolls from back to stomach. 4. Pull self to sitting with better head control when assisted. From lying on back they can reach toys from the side.
8 to 9 months: Maintain sitting while pivoting the body and leans forward when falling backward. Move around while sitting and crawls about five feet. Bounce while assisted to standing and rolls using counter rotation on hips and shoulder. Pull self to sitting by holding on stable furniture.  Maintain hands and knees stationary position while reaching forward.
10 to 11 months: Get up to sitting and reach forward for toys. Creeps forward with hands and knees. Walk sideways while holding on stable furniture and lowers body slowly. Raises to standing while holding onto stable furniture. 5. Balance in standing for three seconds and walk with one hand supported.
12 to 14 months: Maintain kneeling position. Creeps over parent’s legs and creeps up two steps stairs. Creeps forward with hands and feet. Pick up toys, walk about 5 steps, and turns half circle while standing. Roll the dodge ball and fling the tennis ball.
15 to 17 months: Creep backward down stairs about three steps. Walk forward, sideward and backward about 10 feet. Walk on stairs while holding on railings with dominant leg leading. Attempt to kick the ball slowly. Stand in straightforward line.
18 to 23 months: Stand up without holding on furniture or support. Walk on balance beam with one foot off the balance beam. Jump up two inches, down the 4 inches, and forward with one foot leading and jump forward. Kick the dodge ball forward. Pick up tennis ball and throw it while standing. Run about 10 feet. Walk on stairs about four steps with same foot leading while holding on railings.
24 to 29 months: Walk up stairs with alternate stepping but still walks down with same foot leading. Jump down the 16 inches chair or curb. Stand on one foot for a second. Walk on balance beam about three steps. Walk in different directions. Throw tennis or dodge ball about 7 feet forward.
30-35 months: Stand up with less effort. Walk up and down the stairs with alternate stepping. Catch, throw, and kick the ball. Jump down 18 inches chair, over 3 inches obstacle, and forward 24 inches. Stand and hops on one foot.
36 to 41 months: Pedals tricycle about 10 feet. Walk on stairs with alternate stepping independently. Jump forward 26 inches and down the 24 inches chair. Catch ball with hands while elbow bent. Stand on one foot for 5 seconds and hops 5 times.
42 to 47 months: Overhead throw tennis or dodge ball aiming at object. Catch tennis ball. Jump over 6 inches obstacle. Stand on tiptoes with hands on head and on one foot for 10 seconds. Hops on one foot 10 times.

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Different Child Walking Training

There are different way to make your children walk. The main goal when training to walk the children is to discourage them to be over dependent and encourage them to participate more. To make the most of your time to train your children to walk, you need coordinate all of your time with them. You also need to use all the materials that you already have, you don’t need to buy extra equipment. Your couch, wall, children chair, etc. all of them are good enough to train your children to walk.

The most common but effective walking training technique is assisting them on both hands. At the beginning you can fully support their hands high but when they learn, you need to lower the support shoulder level. When they are balancing a little bit you need to decrease the support to just one hand. Then when they started to grasp, just offer one of your finger for support.

The training technique mostly used by motor control training physical therapist  is quick release of support. While your children are supported, quick release of support can be applied while cautiously catching them when they lose balance. Anytime that children fell and you did not catch them, they will lose confident on you that they will not participate next time. Just make your hands close the body ready to catch and avoid falls.

Most of the children want to explore around the house. They want to get up to the couch, wall and other furniture. Use that opportunity to train them to walk. Let them cruse around until they develop strength on their legs and improve their protective reflex. When they are cruising a lot, encourage them to do more by making their favorite place to cruise accessible to them.

Parents can train their children to walk and have fun too by playing “go to daddy or mommy” technique. While standing the baby facing let say the father, ask the baby to go to daddy. The father need to be ready to catch the baby never allowing to fall and allowing to make few steps.

Placing the children standing and leaning back on the wall make them uncomfortable and they tend to move forward to you. You can use this technique using the wall, couch, or small chair. Placing toys on the couch while you hold them facing the toys is also a good motivation to make them walk forward.

In all of these techniques the distance of walking should increase little by little. But when they can’t do far distance just do short distance until they master it. Never let them fall, so close hand catching position should be around their body.  Do not just concentrate on walking, you need to give them feedback. Praise, criticism, and reward are all good tools to encourage them to do better if use properly. Do not rely too much on walker or training belt these can make them over dependent on  support. But if the problem is just the stepping reflex not the weight bearing skills walker and training belt are okay to use.

1. How to support the children to walk
2. Who are allowed to train the children to walk.


Personal Attachment Great Role for Professionals

As a Physical Therapist there are different feeling on how we perceive our work. There are PT who loves their work and there are PT who regrets being a PT. I enjoy being PT because it gives me great importance: when the parents of my patients appreciate me,  when my patient is happy to see me, and when I see improvement from the intervention I made.  I also like the fact that I earn money to do the work that I enjoy.

I apply all my professional skills to every patient that I see but, it always has personal attachment. I am always happy when the patient is improving it does not matter if it is  in my domain or not. It is just fun to see the baby improving their skills from day to day.

When the children are happy to see their PT, most likely they will participate better and improve their skills. When parents are too confrontational with their kids before even the PT had time to have personal connection to their children, it ends up to longer uncooperative therapy. The role of the parents is to be patients for few weeks then when everything does not work out for months that is the time to change the PT. Changing PT is hard for the children sometimes.


“Patience” The Key to Cooperation

When you encounter children that refuse to do anything that you ask or prompt them to do, it is better to wait. When the parent pull their hands to the therapist, most likely they will cry and try to get away. Just show the children the toys encourage the older siblings to play with it and later and when they feel comfortable they will come and play. Do not initiate aggressive physical therapy during initial few sessions.  Most of the children have good response to this approach, although there are few that can only response with authoritative instruction. The problem when you initiate the authoritative approach is when it did not work, they will avoid to see you next time. Crying and temper tantrum are hard to handle in case of the therapist. I rather have happy and willing children for 1 hour than crying and complaining for 15 minutes.  Patience is the key for their cooperation, the parents that usually trying to have their kids rush to therapy always get less beneficial time in the long run. Just a lively conversation to the parents while the children are watching helps too. Later on when they get comfortable enough, you can initiate mild play therapy. When they feel cooperative enough you can start the aggressive physical therapy. Usually, I start with just showing the toy and let them touch the toy. Later on I prompt their hands to the toy. When they refuse contact, you can always start from non contact activities. It is better for the therapist to wait for the children to initiate playful activities with the therapist. Some of the parents are so worried about the minutes that their children are suppose to have. I understand that but work is equal to time and participation. It does not matter how much time I spend with the children, if the children does not want to participate it is equivalent to zero work. If you build good connection with the children at the beginning you will better work result. This approach is applicable to all kinds of children when it does not work you can start with sneak approach.

Simple Solution for Autism

Those children with autism or PDD Spectrum can be train by doing simple conditioning training. In Pavlov Conditioning Theory, Pavlov experimented repetitive ringing of bell while the dog is eating. Later on when Pavlov ring the bell, the dog come, expecting and relating it for food. If you will think about it,  when we do certain activities we expect or relate it to something else. We also need to relate the symptoms of autism or PDD spectrum to something functional. The following are the symptoms of Autism or PDD spectrum: Difficulty to make eye contact, difficulty to communicate with people, repetitive movement pattern, and verbal delays. The autistic children usually like to observe little object,  more than observing people’s face. Those children will improve eye contact when you place small things that they like in between your eyes. For example for those children who really like funny face stickers. Stick funny face stickers in between your eyes during  play activities. After multiple trials, they will start to look to your eyes expecting for happy face stickers. This is same with the dog expecting for food when the bell ring in Pavlov Conditioning Theory. For  those children with repetitive movement pattern are doing it simply because they like it. Most of the ABA or other teachers are stopping these children from doing those repetitive movement pattern. You have to do other way to train those movement  for functional purposes. Apply Pavlov Conditioning Theory by relating to a word. For example, those children that flap their hands over and over, Chant “flap your hand” during this activity. After multiple trials, when, say flap your hands, they will start to flap their hands. For those children who have repetitive movement pattern of marching faster, Chant”march faster” while the do that movement pattern. After multiple trials, when they are not doing anything, ask them to march faster, and they follow my command. That is good communication education for them, because they follow commands. Those children who has difficulty to say words but mumble sounds, give them something they like when they mumble any syllables. For example those children that can mumble “ba”. I give them ball fast, it does not matter if they meant it to have ball or not, the important thing is for them to relate  ball to “ba”. After multiple trials when they say “ba” they will start to look for ball with hands spread asking for it. Then a little bit of correction later on, they can say ball. Relate any syllables to anything they want, here are the list of examples:” ba” for ball, “ssss” for snake toy, “pa” for paper, “da” for doll, “mmmm” for milk or pacifier, etc., you can make up your own. All of autistic children change activities from one thing to another, that is an opportunity for parents or teachers to chant the word stop when you observe that they want to stop. It is not important if it is right time or wrong time to stop at that time,  it is about learning the word stop. It is important for those children with autism or in PDD spectrum to learn the word stop because they usually do thing that is unpleasant to other kids or people. After multiple trials of following on your command, every time they hear commands they expect or relate it to follow it. In conclusion try to apply as much as Pavlov Conditioning Theory to the children with autism.

Most Useful Home EI Equipment

There are different equipment for the children to be used to improve their gross motor functions. Those huge gym ball, and other bulky equipment can be replaced by just manual activities such as doing PT activities on using legs and couch in the parents’  house. Toys are also necessary just for distractions and avoid boredom for the children.  One important equipment that I always bring during EI home intervention is the wooden balance beam. When I stack it together it functions as step stool. When I put it sideways it functions as obstacles, obstacle crossing training.  When I place it from end to end it functions as balance beam. When I apply massage and stretching on the floor it serves as my little bench for me to sit. Most of my children love it because they love to construct things and by using the wooden balance beam, they observe transformation of step stool, bench, obstacle, balance beam, steps balance beam, wobble board, and forward jumping measuring board.

Importance of Surroundings

Most of the time the parents always assume that when they buy walker, bounce seat, etc that those will be main helper for children to functions physically. The truth is nothing can be  better with training the children to do functional activities in natural surroundings. For example having a big gym ball in the house would not mean that the children will have core training exercises. Most of the parents can train their children better without gym ball. The reason is when the gym ball is there it is always hidden, you don’t want the ball blocking you, every time you walk in your living room. Most of the parents that train their children well use their lap for core training exercises.  With PT’s instruction the parent can use their legs to propped them to to standing, challenge their balance in sitting, crawling over and under their legs are very good training too. These are simple training for the children but very effective. When the children starts to cruise the couch, the wall, and furniture are the best equipment better the bars. The reason is it very accessible and they can always find it in any house that they go to. Easy access to training is the best  privilege the children can have. Sometimes the children has severe problem that they really need assistive device, in that case it is okay. But children who is not severely disable should not have special equipment. The more challenges and less assistance that they have the more exercise and training they can do.