Transition: Sitting to 4-point kneeling

Possible Difficulties:

As mentioned in my previous blog children need to repeat movements many times before they are properly learnt.

Children with movement difficulties struggle to do this and may develop abnormal movement patterns in order for them to achieve different postures.

We can help prevent this by teaching and repeating normal movement patterns.

This can often relieve a lot of the frustration for children stuck in static positions who want a particular toy and can’t reach it, or who simply want to change position!

Transitions involve complex movements, varying positions throughout the body.

A child needs to be able to move their arms freely, their shoulders over their hips differently, and legs independently of each other.

No wonder it is hard for some movements to be completed!

But if we are learning the static positions and improving with the transitional postures such as side sitting and side lying, as discussed in the previous blogs, half the battle is won.

Solutions:

Starting with your child sitting between your legs, focus their attention to one side.

Encourage them to reach to that side turning their body and shoulders.

Help them to move their legs into a side sitting position, which will help the body to turn and reach both arms toward the desired toy.

When both arms reach over, the trunk and pelvis will generally follow. If they don’t, give a little more help to move the legs. You can then fold up your leg (to act like the horseshoe in the Playpak) and support the child in the 4-point position.

Using the Playpak we have managed to go through many early positions to help the child learn skills needed to move and become more active.

It is important to remember though, that I often work with children who will not develop in this way.

We may progress no further than the lying postures or skip individual positions due to other factors.

For example, high tone causing over-extension means we would avoid tummy time.

Because I know how important the early development skills are, I will still work on as many as possible with the child even if I know they will not reach certain milestones.

We can still work on the early supportive postures to create the best possible building blocks to give the child the best possible opportunities to succeed.

Kneeling and 4-point kneeling

In this blog we will be looking at how Playpak can assist with the more challenging positions of 4-point (crawling positions) and kneeling, which require greater anti-gravity control. 

The support Playpak offers can allow a child to practice these positions despite being quite a way off being independent in them.

To practice these positions your child should have independent head control in sitting, and only need minimal support to maintain sitting positions.

It will allow the child to experience new positions, which is often both challenging and rewarding for them.

Again we will discuss the various problems children face with these positions.

At the end, I will demonstrate a nice technique to help you practice side sitting and also teach your child how to get themselves from sitting to a crawling position.

As with the sitting blog, you may wish to refer back to my previous guides about earlier positions.

Many positions can be tried using the Playpak – if successful they can be repeated and if not, they can be tried at a later date.

It really is hard to go wrong as long as you remember to support the child in a symmetrical way that allows for mid-line play, whether they are looking in front or to the side.

And remember your therapist will be able to guide you on positions, especially the more challenging positions found in this Blog.

Hands and Knees (4-point kneeling)

Difficulties:

Hands and knees (4-point kneeling) is a difficult position to master.

It requires weight balance over four separate points, and to be able to play in the position, weight must be moved sideways over one arm to then release the other.

This is how babies develop skills to transfer their weight in preparation for crawling.

If your child has never enjoyed tummy time, this can sometimes add to the challenge.

However, the head control and arm stability that being on hands and knees teaches can have far reaching benefits such as improved fine motor skills for later learning, for example to use cutlery or to write.

Children who have low tone may need extra help initially to gain head control and hold up their trunk.

Children with high tone may either straighten (extend) away from the support or bend (flex) into it, so it is important to strike a balance between challenge and ability.

If unsure about these more challenging positions you may wish to seek advice from your therapist or get in touch with us, we may be able to help.

Solutions:

With the trunk supported by the rolls and horseshoe preventing legs from extending or falling out of position, baby has more chance to push up with their hands and get head control.

Try to encourage baby to lift their head to look at you or toys in front.

Aim:

We are looking for equal weight to be placed through arms and knees.

Once in position have a feel of your baby’s arms and legs, slightly lift a hand or a knee to feel if they have any weight going through it.

They should still be in a symmetrical position with their back straight or slightly curved, and definitely not arched backward.

The body will be working on control to hold itself level and the hips and shoulders will be gaining stability to make play, and eventually crawling, possible.

Head control will be improving, lifting and turning both ways.

As baby improves in this position, support sections can be gradually taken away, increasing the challenge.

Tall (High) Kneeling:

High kneeling is useful as baby can begin to take more weight through their pelvis.

They will start to push up from being sat on their feet, to bottom being lifted up and away.

This is using muscles we started to develop when lifting our legs away from the floor in back lying (supine).

A child needs to be able to kneel to successfully crawl and they will go through high kneeling when they learn to transition from crawling up to standing.

Again, this is a more challenging position that you may need to get direction from your therapist on before completing.

There are reasons your therapist may be avoiding this position, for example mastering the earlier skills first. 

Difficulties:

Holding the knees together with the whole body weight going through them can be very hard.

With postures more up against gravity, children with over-active muscles (high tone) may increase further.

Appropriate support needs to be given to prevent W-sitting, which is a position where the child is sat with knees bent in front and their feet by the side of their bottom, toes pointing away from the child.

This position is bad for hip development, and can often become habitual.

If you see your child adopting this position simply swing their legs around so they are pointing forward, or push their knees and feet together so they are kneeling on top of the legs as opposed to the side.

Use Playpak to give support to the side of the legs and to maintain weight through the knees, allowing the child to push up with weight going down through the knees.

It will be difficult for them to initially push themselves up to high kneeling and they will need to rest their trunk on the support.

Examples:

Using both horseshoes the body can be given enough support for baby to lean over.

The strap can hold the bottom slightly though we don’t want to restrict too much the opportunity for them to push up onto knees.

Toys can be placed in front which may encourage more of a 4-point position.

The trunk is nicely rested on the support and there is no over-the-top effort to hold himself up, or arching of the back.

A small roll can be used to help baby keep their bottom off the feet slightly and encourage a more upright kneeling position.

We want to encourage the baby to actively push themselves up onto their knees lifting their trunk away from the support.

Aim:

Initially your child will only be able to rest their bottom on their feet.

We want to encourage them to actively push up onto their knees and hold their trunk upright.

We can play with toys such as balls and blocks to encourage weight through the arms with pushing games or weight through one hand whilst stacking with the other.

This will simulate more of the activities completed in 4-point and tummy time positions.

Some children may not tolerate tummy time or crawling positions, and work in kneeling can help with developing skills missed from those positions.

This however can be complicated and if you are unsure, you should seek advice from your therapist. 

Transition: Lying to sitting

We often work with children in static positions, telling parents to position their child this way and that. However the movement between the positions is just as useful if we are at the point of being able to achieve it.

Teaching rolling may be a skill your therapist has worked with you on, assisting either from the hips or the top arm.

Lying to sitting is a more complex movement that children complete in a variety of ways. Very bendy children may lie on their tummy and almost reverse over their legs, going into the splits and sitting themselves up.

Some push up to almost crawling position, and sit back into a W-sitting position, where the knees are bent and the feet by the side of the bottom. This is a position to avoid!

As I mentioned in a previous blog it is important to work on movement patterns in order to avoid destructive postures. This section will explain one (but not the only) way to assist your child into sitting from a lying position. 

You should be able to try this transition if your child is able to sit with head control and support around the hips only. If you are unsure if your child is ready, you should seek guidance from your therapist. They will be able to guide you if your child is ready to progress to these skills, and the best ways to do it.

Possible Difficulties:

Children need to repeat movements many times before they are properly learnt. This is tough for children with any kind of movement difficulty.

It is important, not only that they master the back lying, tummy lying and side lying positions, but also that we work on the transitions between them. I have often seen children who are excellent in static positions but then get very frustrated at not being able to move out of them.

Transitions involve movement through many planes, with the body bending (flexing), straightening (extending), turning (rotating) and moving individual limbs in isolation of each other. The lying to sitting  transition involves most of the previously discussed positions, with arms lifted up against gravity in back lying, movement to side lying, weight bearing through one arm pushing up to side sitting, then correcting the body to sitting. 

With such a complicated series of movements, no wonder we have to master the individual positions, and consider how children develop leading up to this! 

Solutions:

 Starting with your child lying on their back, hold one hand and assist them into side lying by taking their hand across their body. 

Gently then lead the arm away from the floor, but still slightly in front of their head. They should lift their body slightly and their weight should push through their elbow – it is important you assist and not do all the work for them.

You can tell if your child is pulling back on your hand “bracing” with the arm you are assisting. They should have head control, holding their head up themselves and moving their body to assist. If they are not taking part, it will feel like they are hanging from your hand. As they improve you should be able to help less and less with each part of this transition.

With your assisting hand gently ease it in the direction they need to go to sit themselves up more. Generally this is slightly forward and side. 

This will ease them up into a side sitting position so their weight is now pushing through their hand – they should still be pulling against your supporting hand. If they stop actively pulling up at this stage you can place your other hand on the body and ease them into a sitting position.

If they get themselves up to sitting they may still need a little hand to get their balance! 

You can hold their other hand as pictured or hold onto their body at this stage until they get their balance.

 If you are unsure of any part of this manoeuvre you should ask your therapist for advice. It may be your child is not ready or your handling could be slightly tweaked to ensure your child is active. Again, unless directed by your therapist, this should only be tried when a child has independent head control in sitting and only requires minimal help to maintain sitting balance.

 From these early positions we have taught good movement patterns with rolling and moving to sitting. We have hopefully avoided “cheating” & “destructive” patterns of movement and postures early on in a child’s journey. If the early building blocks are set well, the later building blocks will fall much more easily into place!

Continue on to Part 3 to learn about kneeling and crawling position.

Part 2 Webinar!

Nick talked us through his early intervention tutorials live over a series of webinars in March and April 2016.

Part 2: Sitting Pretty – Transitioning from the early positions, is available below.

 

 

Sitting Pretty – Transitioning from the Early Positions:

In this Blog we will be looking at how the Playpak can assist with early sitting and progressing to more advanced sitting activities. 

We will discuss the various challenges children face with sitting and then at the end we will discuss a nice technique to help you teach your child how to get themselves from lying to sitting.

You may wish to refer back to my previous blog about lying positions to help your child develop the early postures and movements needed to the progress to the more advanced sitting positions.

Early Sitting

Common difficulties:

Children who have low tone often slouch too much when sitting and take a long time to develop the stability needed in their tummy and back muscles to hold themselves in this position.

Children with high tone often increase their tone when challenged and if not supported adequately will adopt poor postures in an attempt to support themselves. They do not choose to adopt these postures and it is not the most comfortable way for them to sit; it is simply their over-active muscles forcing them into unwanted positions.

With early sitting it’s important to remember that it is a very taxing position; inadequate head control with head flopping forward can make it hard for babies and infants to breathe easily – so work within the limits of your child or with guidance from your therapists.

Solutions:

Playpak can be used in a reclined sitting position.

In this position we can work on reaching hands forward for toys. As baby becomes more able and comfortable in this position we can remove the roll at the base of the horseshoes and sit them with their tummy at the back and the strap over their pelvis to give support.

From a reclined position we can also do baby pull-ups encouraging them to maintain their own head control.

Aim:

We want your child to start to develop their core stability to sit themselves up. At first we are aiming for head control, so reclined sitting is OK as fully upright sitting may be difficult to maintain. For a child to use their hands in sitting, it is essential that the trunk has adequate support, much of which can be given by  Playpak with horseshoes, strap and rolls.

At first we want hands coming forward, encouraged by doing the activities discussed in the previous blog. This will help baby to prop up their trunk, until they get adequate trunk control.

Hands on knees or playing with feet are ideal, and when enough trunk support is given or control is gained, then hands will be used to play.

Advancing Sitting Postures

Once baby has enough ability to maintain more of their own sitting postures, they can start to enjoy and improve on it. With Playpak, support can be progressively taken away so the child is more and more active on their own.

Solutions:

We can take away the second horseshoe so the upper trunk isn’t supported.

Sit the “wrong” way in the support.

This will still maintain the leg position preventing looped sitting. Looped sitting is a natural way babies initially learn to sit as it gives them a large base of support. We call it looped as the legs roll outwards from the hips and knees – bending feet then touch each other making a loop with the legs. This in encouraged at first however to progress with sitting so that baby can move from side to side we would like to work on long leg sitting where the knees are straight and point up to the ceiling, as opposed to pointing to the walls.

In this backward use of Playpak we can place items on top of the horseshoe to encourage upright sitting and activation of back and tummy muscles.

Playpak offers many sitting postures and supports but working toward side sitting is where we want to be. We start this by working on “long sitting” with the legs straight out in front. The horseshoe does this for us. 

We can then place objects to the side of the support, with the lap strap removed, so baby has to reach over the edge where they will begin to roll their legs toward that side.

This is the start of side sitting and will progress to baby being able to place weight through their hand on either side. Side sitting is an essential transitional position we move through to get up from lying and to move into kneeling.

Practising this type of position will also help your child learn saving reactions to save themselves when they fall from sitting. This also develops saving reactions for later use – from standing! Consult your therapist for more activities you can complete in side sitting.

Read on to learn about how you can work on lying to sitting transitions.

Part 2 Webinar!

Nick talked us through his early intervention tutorials live over a series of webinars in March and April 2016.

Part 2: Sitting Pretty – Transitioning from the early positions, is available below. 

 

Side Lying

Side lying is an essential position in early static play but also as a transitional position (it helps us move from one position to another, for example, we move through side lying when we learn to roll; we also use it to move from lying to sitting).

Learning side lying is essential for developing the early movement for side-sitting which is another essential transitional position we will discuss later. As a static position it helps us to bring hands together without having to fight against gravity, lifting them above our head or having them trapped beneath us.

This will encourage early play with single hands and both hands at once.

Common difficulties:

Side lying can be a difficult position to maintain. Balancing on the side of the body can increase tone because it is more challenging for your child. Children with raised tone may push their head back further, preventing them from looking at their hands for play.

Children with low tone will struggle to keep their hips in a side lying position as they will have a tendency to roll forwards or backwards. At first we are aiming to support the legs a little bent at the hips (hips semi-flexed) with back support up to the shoulders, and the head looking forward at the hands. When able we will move the back support to free the shoulders.

In that position we can play reaching games in front and behind.

A picture is worth a thousand words, so let’s have a look.

Solutions:

Early side lying can work on upper limb skills. Support as pictured with a strap to help control pelvis and roll keeping head forward, will make this easier for baby to do.

As baby improves in side lying we can lower the support to keep the pelvis on its side freeing the top half of the trunk. This will allow games reaching forward and backward.

Aims:

Maintaining side lying initially will help a child learn how to use their hands in the mid-line of the body, as they are not having to hold them up against gravity to bring them together. Children can also see their hands more easily in this position.

Moving in side lying with pelvis supported, as pictured, reaching forward and back will develop the muscles and movement patterns needed to learn how to roll.

Using the Playpak we have gone through the earliest postures to help the child learn skills needed to maintain positions but also move between and become more active within them.

Back lying (supine) and tummy lying (prone) positions and the movements we have encouraged in them, have allowed us to develop productive movements to learn to roll. These will link up to later skills in sitting and kneeling. It is important to remember though, that I often work with children who will not develop in this way.

We may progress no further than these lying postures for some time, or skip individual positions due to other factors, for example, over-extension of the head and back meaning we would avoid tummy time.

However as I know how important the early development skills are, I will work on as many as possible with the child, even if I know they will not reach certain milestones to ensure the best possible building blocks are in place for them to succeed at more challenging postures and abilities.

Continue on to Part 2 to learn about transitioning from the early positions.

Part 1 Webinar!

Nick talked us through his early intervention tutorials live over a series of webinars in March and April 2016.

Part 1: Starting strong in 3 essential early positions is available below.

 

1.2 Tummy Lying (Prone)

I am sure your therapist will have gone on about the importance of tummy time play. We do tend to love it as it works on many aspects of development all at once!

When first home from the hospital you can play with baby of your chest or on superman position in your arms to develop tolerance of being on their tummy.

When ready to go down onto the floor there are tricks we have to help make it easier and more tolerable.

Initially, babies are quite flexed, which means when you place a baby on their tummy most of their weight will go through their chest. Helping them to straighten the legs behind will move the centre of gravity lower toward their pelvis.

Placing a roll under the chest will move the centre of gravity lower still so that it is easier for them to lift their head and place their arms on the floor in front of themselves.

Some babies don’t like being placed straight on their tummies. If this is the case then try to get there through side lying.

Roll baby slowly from back to front with help to move the lower arms and this may be less of a shock to them than suddenly finding themselves face down on the play mat!

Tummy time can help with developing head control and it will develop the skills essential for progressing to crawling position by taking weight first through the forearms, and then through straight arms.

It will teach a child weight transfer, putting all their weight through one arm to allow them to release the other to play with objects – think weight transfer over shoulders when crawling.

In some instances we actually advise against tummy time, so if you have any concerns or have previously been advised not to do tummy time please consult with your therapist.

Common Difficulties:

Tummy lying (prone) can be a hard position for a child to develop. Not being able to lift their head or push through the arms often makes tolerating the position difficult.

If a child’s preferred pattern of movement is straightening all the time (over-extending), placing them in prone can actually reinforce that – if your child does this, it will be worth seeking advice from your therapist to discuss the best way to do tummy time.

Floppy (low toned) children will struggle to lift their head and push through their arms for support. Not being able to push their legs out behind themselves will make it difficult to move their centre of gravity from their chest (where it starts as a baby), towards their tummy as they push up and lift their head.

Solutions:

Placing chest over a roll will help to bring the forearms down to the floor. If you assist with keeping the arms tucked under it will encourage baby to push through them.

If still unable to lift head you can assist with hand on top of their head gently easing up to say hello. A strap over the pelvis with a child who is still quite flexed in the lower limbs will help stabilise it so baby can concentrate on lifting their head.

Tolerance of tummy time is often limited. Increase it with toys and objects that the child is interested in. I find beads and mirrors excellent at distracting. If your child does not like tummy time try to persevere. Seconds at a time can be a success initially and remember they will build to minutes. If you are really struggling with tummy time it would be worth asking your therapist for advice as more support may be needed.

Aims:

Initially we want baby to move their weight from the chest down to their abdomen so giving support both under the shoulders and over the pelvis to help baby learn to lift and turn head.

Placing weight firstly through forearms and then pushing up to straight arms.

As they improve in this they will progress to moving weight over one arm at a time to play with the other. All these early skills link – once again think baby learning to prop in sitting and crawling.

Read on to learn more about the next of the 3 essential early positions – side lying.

Part 1 Webinar!

Nick talked us through his early intervention tutorials live over a series of webinars in March and April 2016.

Part 1: Starting strong in 3 essential early positions is available below.

 

Part 1. Starting strong – 3 essential early positions
1.1: Back Lying (Supine)
1.2: Tummy Lying (Prone)
1.3: Side Lying

Part 2. Sitting pretty – transitioning from the early positions
2.1: Sitting and Side Sitting
2.2: Lying to Sitting

Part 3. Moving on – kneeling and crawling positions
3.1: Kneeling and 4-point kneeling
3.2: Transition sitting to 4-point kneeling

Part 1. Starting Strong – 3 Essential Early Positions

I am a physiotherapist who works with children with developmental delay, sometimes caused by a diagnosed condition, sometimes of unknown cause and always with varying degrees of severity.

In ALL cases without fail I try to teach parents the importance of early building blocks within child development, which are often overlooked in the pursuit of walking – the skill that, understandably, most of us strive for our children to accomplish.

We know how these early skills link together to make your child reach their potential – and the best bit is, it isn’t much to remember!

In this blog, I will be starting on the earliest of skills from the baby we take home from the hospital playing on their back to the skills leading to tummy time and rolling.  Come back to the next blogs where I will be moving on to sitting & kneeling skills as well as how to encourage the transitions between.

I will be using the Playpak with the children I am seeing. I find Playpak to be one of the most versatile bits of kit available to encourage child development from floor positions up to standing, and it comes in a very portable package.

When I am recommending activities for children to encourage development I advise they should be done throughout the day and not in set physio sessions. So the portability of the Playpak makes it ideal to take to the various places your child will visit throughout their week.

Children learn through new and interesting things in positions that allow their body to achieve.

If they are playing in new positions and experiencing the movements their body can do, then they will be getting the best results.

However if they are adopting destructive positions, learning to accomplish tasks with poor movement patterns, then we are not achieving what we set out to. A destructive position/posture is one which will likely cause harm or increase movement difficulty in the near or distant future.

A poor movement pattern re-enforces destructive postures. Movements need to be repeated many times before they are learned – and often need re-learning when we then move onto another skill.

So if a child learns poor movement patterns they will repeat the movement over and over again until it is established. We need to intervene early to prevent this, to give a child every opportunity to learn the best possible movements and to encourage the best postures, allowing them to better succeed when they progress to positions against gravity.

Let’s look at back lying (supine), tummy lying (prone), and side lying.

1.1 Back Lying (Supine)

Laying on our back is the first position you can really have interactive play with your infant.

It is the easiest way for you to talk to them and establish early turn taking for communication.

Your face, after all, will be the most interesting thing for them at this time!

A typical child will initially be quite flexed with bent arms and legs when first taken home from the hospital.

This, “physiological flexion”, helps the baby to keep their head in the middle and to orientate themselves with the new world they are in – all the additional light, sound and touch they are experiencing having left the womb.

It is common for children with physical difficulties to not have experienced this physiological flexion. Therefore we support them in a back lying position in a way that they can find their middle, their hands and legs, and are able to look around without having to worry about keeping their head still and moving their eyes separately.

Babies move away from the flexed position by stretching their arms and legs independently of each other – if a child has physical difficulties this may be difficult. This is an early building block of moving limbs one at a time independent of the other side, leading to activities such as crawling.

In back lying we can bring feet to opposite hand, working tummy muscles but also separating it from the other foot in the mind’s eye. Supporting a child in a position that allows active movement also helps them develop awareness of their own body by themselves.

Common Difficulties:

Children will often have too much straightening (extension) because of increased muscle tone (hypertonic muscles) or their trunk may be very floppy (hypotonic) making it hard to lift away from the surface.

Their head often stretches back (extends) and turns to one side making it hard for children to learn what and where the rest of their body is, and how their eyes/head relate to it.

They will often struggle to bring their shoulder joints and shoulder blades (shoulder girdle) away from the supporting surface, finding it hard to learn how to use their hands and develop a mid-line awareness.

Alternatively, heavy legs, due to possible low tone or spinal problems, will weigh down the pelvis and bottom of the trunk.

Supporting a more flexed position will make it easier for a child to use their tummy muscles (abdominals) and progress to moving away from back lying (supine).

Solutions:

By making a, “nest”, for baby we are helping them come to a flexed position. This will help them to use their tummy muscles and keep head in the middle.

The shoulder girdle is forward making it easier to use the arms and bring them in front of the head, and the hips are supported making it easier to lift the legs. We can easily work on looking at objects being moved from left to right and reaching games with the arms. Looking at our feet is an excellent way to introduce them to baby.

Aims:

Simple support to the shoulder girdle can help baby maintain mid-line of their head – allowing them to focus on the toy, as well as giving them the opportunity to reach up with their hands. Babies, in truth, haven’t got a clue what their hands are to start with – this gives them an opportunity to play with them and learn about them.

I often think, “Did the child I am seeing ever get a chance to take their hands to their mouth?” This early skill/opportunity can really help a child then progress to rolling and propping in prone & sitting – then onwards to crawling.

Think, how can we roll if our arms are pinned to the floor by the weight of the shoulders?

How can we learn to sit if we are unable to place our hands forward?

And how can we crawl if we have never taken weight through our arms? This position can also help develop awareness of mid-line, tracking and head control.

Read on to learn about the next of the 3 essential early positions – tummy lying

Part 1 Webinar!

Nick talked us through his early intervention tutorials live over a series of webinars in March and April 2016.

Part 1: Starting strong in 3 essential early positions is available below.