“Come look at his knees,” a concerned parent asked me.

The toddler climbed off the couch and ran, no, barreled towards me.

“Look! When he stands, his knees are touching!  What’s wrong with his legs?”

“He’s 2-years-old, right?” I asked.

“Yes,” said the mom.

“Nothing, this is typical knee alignment for his age.  Let me explain…”

Parents are most concerned about bowlegs (genu varum) and knock- knees (genu valgum) in their children. As early intervention providers, we are in a unique position to educate parents and caregivers about the normal development of hip and knee alignment, as well as assist families in deciding when it is appropriate to seek the expertise of an Orthopedist.

As a child grows, from infancy to childhood, the alignment of the knee also changes. At birth, newborns are bowlegged (genu varum).  The infant’s legs slowly straighten and between 12-24 months old, the legs reach a neutral alignment. It has been suggested that the alignment of the knees improves as weight bearing increases during standing activities between 12-24 months. Knock-knees (genu valgum) reach its peak between the ages of 2 and 4 years-old and then gradually decreases. The final knee position differs depending upon the gender of the child. Sixteen-year-old females tend to have slight knock-knees as their pelvises are wider. Sixteen-year-old males tend to have slight bowlegs as their pelvises are narrower.

It makes sense then, that the reason the greatest number of referrals to Orthopedists of children between the ages of 2 and 4 years-old are for concerns of knee alignment. That’s when knock-knees reaches its peak! The change from straight (or neutral) legs to knock-knees can be disconcerting for parent.

There is good news! Eighty percent (80%) of children with bowlegs before age 2 years-old and knock-knees before age 6 years-old, will improve knee alignment spontaneously. There are various opinions about when or if knock-knees and bowlegs warrant treatment. Research has found that twister cables and other conservative, non-operative treatments are unsuccessful. Evidence suggests that therapists should measure hip range of motion every 6 to 12 months to document femoral anteversion (inward rotation of the femur; resultant knee turning inward).

Children should be referred to an Orthopedist if they have:

– Excessive knock-knees or bow legs

– One leg is more or less knock-kneed or bow legged than the other (asymmetrical)

– Knock-knees or bowlegs progressively increase

– Pain with putting weight on their legs

– One leg longer or shorter than the other leg

– Knock-knees or bowlegs persist beyond 7-8 years-old

– Position of the knees create significant cosmetic and functional disability

How have you addressed this concern with the families you work with?

References

Cheng JCY, Chan PS, Chiang SC, HUI PW.  Angular and rotation and profile of the lower limb in 2,630 Chinese children.  Journal Of Pediatric Orthopedics.  1991; 11:154-161.

Heath CH, Staheli LT.  Normal limits of knee angle in white children – Genu varum and genu valgum.  Journal of Pediatric Orthopedics.  1993; 13:259-262.

Staheli LT.  Fundamentals of pediatric orthopedics.  4^th ed.  Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins; 2008.

Campbell S, Vander Linden DW, Palisano RJ.  Physical Therapy for Children.   3rd ed.  Missouri: Saunders Elsevier; 2006.

Effgen S.  Meeting the physical therapy needs of children.  2^nd ed.  Philadelphia: FA Davis Company; 2013

Sass P, Hassan G.  Lower Extremity Abnormalities in Children.  American Family Physician.  2003; 68(3):461-468.

Ganger R.  Lower Limb Development.   www.scribd.com/doc/55666675/Lower-Limb-Development-Ganger.  Published 2011.  Accessed August 2, 2014.

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Toddlers.  They weeble, they wobble and they fall down.  A lot!  The question is really, how often is too often?  Toddlers are still remarkably unstable and often over-confident.  Two year olds are much more confident with their physical abilities but they don’t have a very good idea about when to stop.  They love to run, swing, climb, and ride on toys they can push with their feet, but they can easily get it wrong so bumps and minor falls are common. The average two-year-old falls 38 times a day.   It will take time before the toddler achieves the skills, strength, balance and rhythm of a secure walker.  In fact, pediatricians say it is normal for toddlers to fall, even on flat ground, until 4 years old.  Toddlers are learning how to coordinate their movements for this new skill of walking.  I like to remind my families that the first time they learned to ski or roller skate they fell a lot too!

In a study of 130 toddlers (12 and 19 months old), the researchers found that the toddlers fell on average 17 times an hour.  If they were new walkers, they fell an average of 69 times an hour.  The toddler’s height and flexibility make short falls relatively harmless.   Thankfully, most bumps require a kiss and maybe even some ice to make the boo-boo better.

There are several other reasons that a toddler can fall:

1. Toddlers grow at a rapid rate, and shoes that fit one day may not fit the next.  If the toddler’s shoes are too small, he can suddenly start tripping, falling, or having other issues walking or running about.
2. If a toddler has had a sudden growth spurt, he will need to find a new center of balance.  This might mean more spills as he figures out how to move his new, suddenly taller body.
3. Most toddlers are farsighted and have trouble judging distances.⁴  If your toddler seems to constantly “over-step” stairs or misjudges picking up toys, he may need to be seen by an ophthalmologist, as these behaviors may indicate vision concerns.

Here a few ideas you can share with families to help decrease injuries while still allowing the toddler to explore their environment.

1. Childproof with walking in mind.  Check for sharp corners on counters and coffee tables.  Check for unstable end tables and chairs.  Watch for dangling cords from electronics and blinds.  Keep drawers, doors and appliances closed when the toddler is moving.
2. Avoid extra-hard surfaces.   Try to avoid surfaces like concrete, brick, tile, slate, and stone floors or hold your toddler’s hand while he walks over these harder surfaces.
3. Bare feet!  Bare feet are preferred, especially when walking around the home.  If a toddler wears socks use nonslip bottoms.  If using shoes, make sure they fit properly and have good traction.
4. Try not to overreact.  Avoid rushing to your child and making a big deal every time he falls.  It can make him unnecessarily fearful of falling and can discourage him from exploring.

As early interventionist, what other ways can you encourage families to let their toddlers safely explore their environment?  Have you ever provided a fall log to a family?

References:

1. Toddler Health: Bumps, Bruises, & How to Tell if it’s More Serious.  http://smartmomma.com/Toddler/bumps_and_bruises_toddler.htm
2. Miller D.  (November 1999).  Toddler falls: When should you worry?  http://www.cnn.com/HEALTH/children/9911/10/head.falls.wmd/
3. Adolph KE, Cole WG, Komati M, Garciaguirre JS, Badaly D, Lingeman JM, Chan G, and Sotsky RB.  n.d. How do you learn to walk? Thousands of steps and dozens of falls per day.  Psychological Science. 1-14.  http://www.psych.nyu.edu/adolph/publications/Adolph%20EtAl%20HowDoYouLearnToWalk.pdf (PDF, New Window)
4. Clumsiness (Frequent Falls & Bumps).  http://www.whattoexpect.com/toddler/behavior/clumsiness.aspx

This information is for educational purposes only. For specific medical advice, diagnoses, and treatment, consult your doctor.

Kim Lephart, PT, DPT, MBA, PCS is a dynamic pediatric physical therapist with nearly 20 years of experience.  She is board certified Pediatric Clinical Specialist.  She is a team player who enjoys the collaborative model of working with parents, teachers, occupational, speech and vision therapists to meet a child’s individual therapeutic needs.  She has worked with children in a variety of clinical settings including private clinics, school systems, home health, outpatient rehabilitation, aquatics, and early intervention programs.  She currently works for Rappahannock Rapidan’s Early Intervention Program.  Of all of Dr. Lephart’s accomplishments both professionally and personally, she is most proud of her four children.  She is a busy mother of children ranging in ages from high schooler to pre-schooler

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What Does the Research Tell Us?

Physical therapy and helmet treatment are considered the conservative strategies for positional torticollis, congenital muscular torticollis, and deformational plagiocephaly.¹  Retrospective and prospective studies of conservative measures have reported, “good to excellent results, with success rates ranging from 61% to 99% when intervention was initiated before one year of age.”^(p.370)2   Ellen Brennan, PT, DPT, physical therapist, Children’s Specialized Hospital stated, “successful intervention for the child with torticollis is fully dependent on how successful the caregivers are in integrating treatment strategies into the child’s daily routine.”³

Strategies for Stretching the Infant with Torticollis

Most of the infants I work with don’t like the stretches for torticollis, not because it causes them discomfort, but because they do not like being restrained.  If I can make the stretches and exercises more tolerable for the infant, then the likelihood that the caregivers will be successful with the exercise program will increase.  Below are some simple strategies to incorporate into an infant with torticollis’s daily routine.

If you are not a physical therapist, you can still help families implement these stretches but be sure that a PT shows you how to do them with the child and family first!

Rotation stretch: When holding the infant’s shoulder down and gently rotating the infant’s head all the way to one side until the chin is over the shoulder, encourage the infant to look to that side by:

• Having a caregiver, peer or sibling play peek-a-boo
• Activate a musical toy
• Look at themselves in a safety mirror
• Reach for a household pet

Side-bend stretch: When holding the infant’s shoulder down and gently, but firmly, side-bend the infant’s ear to the same shoulder, encourage the infant to maintain this position by encouraging the caregiver to:

• Blow “raspberries” on the side of the neck that is being stretched
• Give “Eskimo” kisses to their infant’s nose
• Kiss the baby on the side of the neck that is being stretched
• Chat with the infant
• Sing songs so that the infant watches the caregiver’s face

Here’s a video illustrating both of these stretches:

Football hold: For example, if the infant has left torticollis, the infant’s left ear rests against your left forearm as they face away from you.  Place your other arm between the child’s legs and support the child’s body. Encourage caregivers to carry the infant in this hold as much as possible.

This video shows the “Football hold” – a great way to hold a baby with Torticollis to stretch the tight side (tight side is against the caregiver’s forearm):

Tummy time: Place the infant on their tummy and place toys to the opposite side of where the infant normally looks.  Encourage the infant to look to that side by:

• Blowing bubbles for them to reach out to
• Peers or siblings to entertain them
• Activate musical toys
• Look at themselves in a safety mirror
• Tickles, songs, funny faces

Rolling:⁴ Encourage the infant to roll towards the tight side, first on flat surfaces then on inclines.  This exercise can be incorporated during:

• Diaper changes
• Changing clothes
• Tummy time

Head/body righting reactions: Make a game of holding the infant facing you at eye level.  If they are heavy, you can rest their bottom on the top of your knees.  Slowly tilt the infant towards their tight side.  As you slowly tilt them back to eye level, encourage them to bring their weak side up by:

• Chat with the infant
• Sing songs (e.g. I’m a little teapot)
• Make funny faces
• Make silly noises                                                          

Feeding: When bottle feeding the infant, present the bottle so they look opposite to their preferred side.

• Hold the bottle towards the tight side
• Encourage the infant to finish the bottle in this position

Do you have some strategies to make torticollis exercises and stretches more tolerable for the infant or family?  Share your ideas on how to incorporate these exercises into the family’s daily routines!

References:

1. Van Vlimmeren LA, Helders PJM, Van Adrichem LNA, Engelbert RHH.  Torticollis and plagiocephaly in infancy: Therapeutic strategies.  Pediatric Rehabilitation, January 2006; 9(1):40-46.
2. Campbell  S, Vander Linden  D, & Palisano R. (2006). Physical Therapy for Children, third edition. St. Louis: Saunders Elservier.
3. Mayer R.  Tackling Torticollis.  Advance for Physical Therapy & Rehab Medicine, January 2012.  Retrieved May 23, 2013 from: physical-therapy.advanceweb.com/Features/Articles/Tackling-Torticollis.aspx
4. Long T, Toscano K.  (2002).  Handbook of Pediatric Physical Therapy, second edition.  Philadelphia:Lippincott Williams & Wilkins.

For more info on torticollis, motor delays and development, visit the VA Early Intervention Professional Development Center’s Motor Delays & Disabilities page.

Kim Lephart, PT, DPT, MBA, PCS is a dynamic pediatric physical therapist with nearly 20 years of experience.  She is board certified Pediatric Clinical Specialist.  She is a team player who enjoys the collaborative model of working with parents, teachers, occupational, speech and vision therapists to meet a child’s individual therapeutic needs.  She has worked with children in a variety of clinical settings including private clinics, school systems, home health, outpatient rehabilitation, aquatics, and early intervention programs.  She currently works for Rappahannock Rapidan’s Early Intervention Program.  Of all of Dr. Lephart’s accomplishments both professionally and personally, she is most proud of her four children.  She is a busy mother of children ranging in ages from high schooler to pre-schooler.

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I typically start my early intervention sessions by asking the family to “brag” about what is new and exciting in their child’s life.  Usually, the family will also bring up what activities are challenging for them.  If not, I will ask the family what are their concerns?  Admittedly, these concerns are more child-focused and less family-centered concerns, although there are times when family concerns are expressed and I help the family connect with the right resource.

Life Participation for Parents Questionnaire

I recently used the Life Participation for Parents (LPP) questionnaire with an early intervention family as part of an assignment for a class in my clinical doctorate program.  The LPP was developed by Patricia E. Fingerhut, OTR, PhD in 2005 and indicates individual obstacles to life participation for the child, parents, and other family members.^1-3  The LPP consists of 23 questions associated with activities the primary caregiver is involved in that may be affected by bringing up a child with special needs.   The LPP uses a 5-point Likert scale and there is opportunity for the caregiver to offer qualitative comments to provide the therapist with more information and focused follow-up.  The LPP takes about 10 minutes for the family to complete and less than 10 minutes for the early interventionist to score.

Learning New Things from the LPP

The use of the LPP afforded me the opportunity to learn things that surprised me, things that pleased me, and things that I had not considered before with my early intervention families.  In reviewing the LPP, I was surprised that despite this Mom’s excitement over her child learning to use a walker, she did not view her child as an “independent” walker.  Through follow-up conversations, I learned that the walker creates stress for this Mom during public outings due to the unwanted attention the device brings to the family.  I was pleased to read that the Mom felt that “the exercises and tasks the therapist suggests are easily worked into our normal daily activities.”

One of the concerns that arose from the LPP was that this Mom did not know she could catheterize her child “on the go” and it limited where the family went and how long they could go on outings.  This subject had not come up in previous treatment sessions and allowed me to encourage the family to problem solve how to use their vehicle as a place to catheterize while on outings.

I think the LPP is a useful vehicle to assist early interventionists in starting a dialogue with families in asking questions that might not normally be discussed during their typical session and determining how to better assist the family with their concerns.  I will be using the LPP to adjunct my services to early intervention families and assist in developing family-centered interventions.  Is the LPP something you see yourself using?  How will you incorporate the use of LPP in your early intervention practice?

Click here for a pdf copy and description of the questionnaire: Life Participation for Parents Questionnaire (PDF, New Window).

If you want to learn more, check out Dr. Fingerhut’s recent article on the LPP:

Fingerhut, P. E. (2013). Life participation for parents: A tool for family-centered occupational therapy. The American Journal of Occupational Therapy, 67(1), 37-44.

References:

1. Hinojosa J, Sproat C, Mankhetwit S, Anderson J.  Shifts in parent-therapist partnerships: Twelve years of change.  Amer J of Occup Ther.  2002.  56(5):556-563.
2. Roberts K, Lawton D.  Acknowledging the extra care parents give their disabled children.  Child Care, Health & Develop.  2001.  27(4):307-319.
3. Rosenbaum P, King S, Law M, King G, Evans J.  Family-centered service: A conceptual framework and research review.  Phys and Occup Ther in Peds.  1998.  18(1):1-20.

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In my previous post I discussed five tips that will help early interventionists in collaborating with families to embed therapeutic strategies into their daily routines.  To review, the tips are: start with a routine based interview, incorporate family goals into strategies, set up the environment, follow the family’s and child’s lead, and be creative.  In this post I wanted to give early interventionists specific examples.  Not all families go to the park or take their children shopping, so I tried to use activities that most families do daily.  The following are some ideas for incorporating intervention strategies into daily routines:

Meals

Language – can work on signs “more”, “eat”, “drink”, “please”

Fine motor – fine pincer grasp to pick up finger foods, hold cup, practice using utensils, wiping face and hands (also a sensory activity)

Gross motor – practice pulling up to stand, climbing up into high chair or regular chair

Social/Emotional – practice playing peek-a-boo with wash cloth during cleaning up after meal

Sensory – opportunities to play with their food, finger painting with applesauce, pudding, spaghetti, etc.

Diaper changes

Gross motor – rolling, transitioning in/out of sitting, pull to sit for head control, stretches (because there are many opportunities to stretch throughout the day and it’s natural to stretch to take off/put on clothes and diapers)

Fine motor – playing with toys during changes, practicing zippers, large buttons

Language – work on opposites: on/off, up/down, and body parts

Laundry

Gross motor – push basket (upright or upside down), pull to stand at over turned basket, toss socks into basket

Cognitive – sort colors, match socks

Sir John Lubbock once said, “What we see depends mainly on what we look for”.  As early interventionists, what opportunities do we look for?  What are some other daily routines families have?  We would love to hear your ideas for embedding strategies into specific family routines.

The post Embedding Strategies into Family Routines: One PT’s Perspective (Part 2) appeared first on Early Intervention Strategies for Success.

I agree with Mahoney, Robinson and Perales (2004), “….the time has come to stop talking about parent involvement and to commit to learning how such involvement can be accomplished across a range of family constellations, circumstances, and values.”  When I first start working with a family I explain that there shouldn’t be a “therapy” hour, rather the family should have lots of ideas on how to “work” with their child by incorporating strategies into activities they are already doing throughout their day.  The following are a few tips that will assist the early interventionist in learning how to embed strategies into a family’s natural routines.

Start with a routine-based interview.

The early interventionist could use a formalized, extensive routine-based interview like McWilliam’s RBI (2004).  I tend to do a less formal interview: I ask the family to tell me about a typical day (starting from when the child wakes up until they go to bed for the night).  If the family hasn’t mentioned it during their accounting of a typical day, I ask about specific activities they do: shopping, walks, visits to friends, parks, library, day care, etc.

Incorporate family goals into strategies

This is important for a couple of reasons.  First, because the family’s goals help shape the child’s IFSP outcomes.  Second, when our approach is compatible with family routines and priorities, the result is collaboration among all team members (Blythe, 2012).  Lynne Blythe, local system manager of the Infant and Toddler Connection of Rappahannock-Rapidan suggests an equation: Family identified routines + prioritized outcomes = Collaboration + Cooperation “Take away any factor and the equation becomes unbalanced” (Blythe, 2012). Sometimes this requires the early interventionist to explain how the strategy is a precursor to an outcome skill.

Set up the environment

While changes to the actual family activity should be avoided, sometimes it is necessary to modify the environment where the activities take place.  For example, let’s say a family’s outcome is for their child to use words and start walking like their cousin’s same aged child.  This child’s toys are always on the floor for easy access during playtime.  Moving the toys up on top of the coffee table encourages the child to either use his words to request a toy or to pull up to stand to reach the toy, or both!

Follow the family’s and the child’s lead

I recently had a child with a diagnosis of Spina Bifida who was resistant to walking with her reverse walker.  I suggested making the walker a fun activity by adding a basket to carry a favorite toy.  The Mom put the child’s favorite bear in the sling seat and encouraged the child to push the walker from behind like a stroller.  Was it the correct way to use the walker?  Technically speaking, no, but for our purposes, heck yeah it was!  As a pediatric physical therapist I’m trained to break developmental activities up into sequences.  First a child crawls, then cruises then walks.  First a child must be comfortable on an even surface with an assistive device before you introduce uneven surfaces.  As an early interventionist I have learned to keep that training in mind, but follow the family’s lead.  This same child refused to walk more than a few feet with her walker inside.  Admittedly, I was running out of ideas.  That weekend I received a video from the Mom of her daughter walking – outside, in gravel!

Be creative!

This is the fun part!  For instance, going for a walk provides numerous opportunities to incorporate multiple developmental strategies: squatting to pick up rocks or flowers, marching, going up on toes to reach for leaves, labeling objects and colors, experiencing different textures on hands and feet, etc. Can you use a favorite toy in a new way?  Can the siblings be models for the strategy during the naturally occurring activity?  As an early interventionist you’ll have to think on your feet and outside the proverbial box!

“Interventions fail to be implemented and sustained when they do not fit the daily routine of the family…when the intervention cannot be incorporated into the daily routine, or when the intervention is not compatible with the goals, values, beliefs of the parents” (Bernheimer & Keogh, 1995, p.424).  I am just one pediatric physical therapist.  As early interventionists we learn the most from each other.  What are some specific examples of how you have incorporated interventions into the daily routines of your early intervention families?

References available upon request.

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