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by Shelley Mannell

Core Stability for Kids with Special Needs

January 9, 2013 in Featured by Shelley Mannell

 IF YOU GIVE A KID THEIR CORE…….

One of my favourite children’s books is “If You Give a Mouse a Cookie” – I love how the beginning of the story is also the end of the story.  As a Physical Therapist I understand that success in motor skills begins and ends with core stability; the core supports every skill from eating to printing to walking to basketball.  And I think it’s outstanding that so many people are now talking about the importance of core stability for kids.

However, I think we need to bring some clarity to our core conversations.  Specifically, there are inner core muscles and outer core muscles.  The four inner core muscles stabilize our spine and pelvis before every movement that we make.  (FYI these are: the respiratory diaphragm, the pelvic floor, the transversus abdominis and the multifidus.) And our research has shown that there is a key to building core stability – we need to have neutral alignment of your rib cage and pelvis and we need to be able to breathe into the front, back and especially the sides of our rib cage (we call this “umbrella breathing”).  This is the way we efficiently stabilize our body in preparation for movement.

There’s another bonus to teaching children to engage their core.  As children get that all important alignment and learn to breathe fully with their diaphragm, they impact the calming nervous system.   It turns out that when we belly breathe or when we breathe with our upper chest, we don’t impact those nerves; we calm only when we breathe by fully expanding our diaphragm.

For many reasons, children with special needs have difficulty activating their inner core. They actually do the opposite; they hold their breath in order to create stability. Sometimes they begin this almost as soon as they are born.  And difficulties with muscle tone (both low tone and high tone) make neutral alignment difficult, which interferes with inner core activation even further.  A nervous system stuck in the “fright or flight” response interferes with core activation too.  All this contributes to poor movement quantity and quality.  It sounds like an insurmountable problem but thankfully it’s not.   We are teaching therapists about inner/outer core relationships, their impact on motor skills and how best to address them in treatment, activities of daily living and recreation (http://bit.ly/WRVMI5).

So when children with special needs activate neutral alignment and umbrella breathing, every activity becomes a core activity.  And if you give a kid their core, you are preparing them for a lifetime of successful movement.

photo credits www.friendshipcircle.org

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Shelley Mannell,  PT, HeartSpace Physical Therapy for Children www.heartspacept.com

@heartspacept on Twitter or HeartSpacePT on Facebook

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by Shelley Mannell

Connecting “Tummy Time” and Development

June 7, 2012 in Featured by Shelley Mannell

The favorite toy in my house when my kids were growing up was an old-fashioned set of Tinker Toys.  Bought as a spur of the moment gift at Christmas it turned out to be the most popular toy for years. The kids could make anything out of it, as long as there were enough connectors.  With endless connectors came limitless possibilities for play.

The same can be said for the tummy position for infants.  It’s not just a motor milestone, it’s a connector piece.  Being on their tummy allows babies to activate their labyrinth or balance system that helps them understand where they are in space.  They experience touch along the whole front surface of their body and this develops

body awareness.  They learn to push off of the surface, first with their arms and then with their legs, activating/strengthening many muscles against gravity.  These experiences build the sensory and motor wiring in the brain that supports vision, core strength, balance and more complex movement.

That’s not to say that babies who can’t be on their tummy for some reason have to miss out on these connections.  As therapists we talk about “modified positioning.” All this really means is the child doesn’t have to be flat on the floor in order to get these benefits.

Holding a baby on your chest is a modified tummy position.  So is letting them push off your chest as you are sitting reclined.

And of course, lying or standing against a surface is also a modified tummy position – that’s one of the reasons why therapists love therapy balls!

And if for some reason an older child can benefit from more time in prone, there are lots of fun ways to accomplish that.

In the end, tummy time in all its forms provides key connections between children’s brains and their bodies.  And just like Tinker Toys, those connections provide limitless possibilities.

Shelley Mannell is a Physical Therapist in St. Catharines, Canada with 25 years of experience supporting children and families on their journey to independence. You can read about HeartSpace Physical Therapy for Children at www.heartspacept.com or follow Shelley on Facebook at HeartSpacePT or on Twitter @heartspacept. 

Photo credits:

tinker toys: Growing Tree Toys

ball therapy: shutterstock.com

girl on hammock swing: DreamGYM indoor gyms blog (www.dreamgym.wordpress.com)

baby on chest: Shelley Mannell, author of post

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by Shelley Mannell

Round & Round the Garden…(for core strength)

March 15, 2012 in Ask the Physical Therapist, Community Wisdom, Featured by Shelley Mannell

This is a classic – professionals recommend that children who have poor core strength do wheelbarrows and planks as exercise but children can’t complete these activities unless they have good core strength.  I feel dizzy trying to sort my way out of this so I suggest we all hop off the merry-go-round and find out what the core muscles are and how they work.

1. Our inner core muscles turn on first.

We now know that the inner core consists of 4 muscles (the respiratory diaphragm, the pelvic floor, the transversus abdominis and the multifidus).  They function to give us a stable spine and pelvis before movement begins and they activate as a team in the same way before every movement that we do. During the process of development, the inner core muscles become active and efficient during the first 2 – 3 years of life. For our children with motor challenges, the inner core muscles do not become efficient due to neurological, sensory and alignment issues.  

2.  The timing of outer core muscles depends on the task.

Unlike the inner core muscles, outer core muscles activate differently depending on the task. Superficial abdominal muscles, hip and back muscles are all members of our outer core groups.  The inner core muscles create an anchor at the center so the outer core muscles have something to stabilize on and this allows the outer core to work efficiently.  We call this partnership of inner and outer core muscles the body’s “core strategy”.  When the inner core muscles are not active, children over-recruit outer core muscles instead and this causes clumsy/uncoordinated movements and can also lead to pain. (This happens with adults too.  Please go to www.juliewiebept.com for great information about core function in adults.)

3.  The inner core muscles are easily overwhelmed. 

The inner core muscles are easily overwhelmed by other muscles.  A sure sign that the inner core is not active is breath holding to accomplish a challenging movement.  Babies and toddlers do this naturally when accomplishing new skills but they move quickly through this as they develop. Children with motor challenges continue to use breath holding as their way of creating a stable center.

Now that we understand more about our core muscles, how do we apply it to help children with motor challenges?

1. Stop thinking about core exercise and start thinking about core strategy.

Core exercises (crunches, wheelbarrow, crab walk, planks, stability balls – the list is endless!) are something separate in a childs’ day but in reality core strategy is something that should be present throughout the day.  Building alignment builds core strategy, which is critical for endurance and strength. 

2.  A is for alignment.

Our children need to experience better alignment.  Many of our children tuck their bottom under (photo 1) and shift their rib cage back (photo 2) or pop their bellies out and shift their rib cage forward (photo 3) in an effort to keep their body balanced.  Alignment of the rib cage over a neutral pelvis is needed to be able to activate the inner core muscles (photo 4).  No amount of telling children to “sit up straight” will help; kids actually need to be able to breathe properly to activate the muscles and maintain the posture.   

 

3.  Everybody breathe.

When you are with a child, listen to their breathing.  If they are breath holding prior to/during a task, remind them to breathe. Many of our kids also overuse their shoulders or belly during breathing (when you ask a child to take a deep breath, do they lift their shoulders or puff out their belly?).  We need to retrain the respiratory diaphragm by encouraging a full breath with expansion of the lower rib cage; we call this an “umbrella breath”.  Then the inner core team can provide that all-important central stability.

4.  Movement should be fun.

Ultimately we want our kids to take their core with them wherever they go!  They need it sitting, walking, running, playing hopscotch, skipping rope, hula hooping, rock climbing and rollerblading.   If we train the inner core to come online first, then we can put that into play (and school and sports too!).   In that way, every activity becomes a core activity.  So in my practice you’ll find my clients working their core in everything they do – but the wheelbarrows stay in the garden and planks are just pieces of wood.

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For more information on Dynamic Core for Kids or Physical Therapy for children with special needs, please visit Shelley’s website at www.heartspacept.com/blog.  For continuing education workshops, visit www.heartspacept.com/workshops.  You can also find Shelley on Twitter @heartspacept, Facebook at HeartSpacePT or Pinterest at heartspacept. 

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5 Practical Motor Planning Tips

December 7, 2011 in Ask the Physical Therapist, Community Wisdom, Featured, Featured Member by Shelley Mannell

We used to believe that motor skills developed in a very linear fashion and that most movements were pre-programmed in the brain.  Now we know that the brain constantly shapes our movements, before, during and after they occur, so that we can be successful in all our tasks. We also know that motor skills are based on processing of sensory information:  muscles, vision, hearing, vestibular and proprioception all combine to inform the brain about movement.  In some children with motor challenges however, the brain may not process this information as efficiently and this leads to difficulties with posture, balance and motor skills.  But there are ways to help.  Here are some practical suggestions:

1.  CALM THE NERVOUS SYSTEM

Increased stress/anxiety interferes with the “just right state” for learning motor skills. Strategies to calm the nervous system include:

Umbrella breathing: have the child sit or lay in a comfortable position.  Encourage them to take a deep breathe, expanding the sides of their lower rib cage (more than their upper chest or belly).  Let them breathe in and out easily, relaxing with the breath.  The iPod/iPad apps iBreatheFire and Balloonimals are fun for helping kids with a bigger breath out (that means they had to take a better breath in!).

Imagery:  Develop a very short story using an image that is calming for the child.  Make the story multi-sensory; feel the warmth of the sun on your face, the squish of the sand under your feet etc.  Re-tell the same story periodically and pair it with umbrella breathing for a calming effect.

2.  SUPPORT THE VESTIBULAR SYSTEM

The vestibular system is a powerhouse of the brain.  It assists in emotional self-regulation, anti-gravity muscle tone, central stability of the body, visual tracking and balance.  Difficulties with the vestibular system are common in children with motor challenges.  We can help to prepare for balance and motor skills by providing input to the vestibular system prior to movement.

Linear movements: large and small movements forward/back, side to side or up/down stimulate part of the vestibular system that is associated with muscle tone.  Running, swaying, or even head nodding/shaking can prepare the body for movement.

3. OPTIMIZE VISUAL INPUT

We’ve just talked about vestibular input but also visual input has a huge impact on balance and movement.  We use vision as our primary sense for balance until age 6 and many children with motor difficulties continue to use this sense as a primary source of information.  However they may also have difficulty using their eyes together and may also not be able to process visual information well.  Colour changes what information reaches the brain from the eyes.  Some children can benefit from using colour to enhance the visual information available during balance and movement tasks.

Coloured glasses: these are available in a rainbow of colours.  You can find them on the internet (www.colorglasses.com gives you a range of options) but you can also often find some colours at your local dollar store.  Experiment with what colour your child likes.  Children who are sensitive to bright light tend to prefer the blue/purple end of the colour spectrum and children who are sensitive to visual input in general tend to prefer the red spectrum.  The child can use these glasses when learning a task to assist with processing visual information for balance and when dealing with moving objects (throwing and catching balls).

4. INCREASE CORE STRATEGY

Many people talk about core muscles however our understanding of core stability has progressed a great deal in the past few years.  We now understand that 4 inner core muscles are wired to work as a team before movement begins; they prepare a stable trunk for all movements.  One of these muscles is the breathing/respiratory diaphragm.  When children don’t have a stable center they substitute breath holding to create stability.

“Blow before you go”: using the breath to support central stability is key.  Cue the child to take a breath in and then begin to blow out before they start to move. In this way, they are helping the body to use the inner core muscles for central stability rather than compensating with breath holding.

5. PROBLEM SOLVING PROMOTES LEARNING

Engaging more areas of the brain in the learning of a motor task assists with processing of more information.  Asking questions rather than giving solutions promotes this process.

Ask open-ended questions when learning motor skills: rather than providing solutions (“let’s try it this way”), ask questions that help the child think through the skill and consider the pieces that can be changed (“did the ball go where you wanted it to?”, “how did standing on one foot feel?”, “what could we change to see if that could work better for you?”).

Multi-sensory input movement usually works best, because this is how the brain is meant to function.  The key to success is finding the combination of inputs that works for each child as they learn about their posture, balance and movement.

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For more information about Shelley, Physical Therapy for children with motor challenges or workshops for professionals, visit Shelley at www.heartspacept.com

 

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DYNAMIC CORE FOR KIDS CASE STUDY: 9 year old child with ASD

June 13, 2011 in Featured by Shelley Mannell

At four years old Sindy was diagnosed with low tone and gross motor delays. Subsequent issues included balance, gross and fine motor delay, increased frequency of muscle sprains, anxiety, sensory processing challenges.  Last year at age 9, she was diagnosed with high functioning autism.

Presentation immediately prior to Dynamic Core treatment:

Sindy initially presented with decreased strength and endurance issues in her arms, legs and trunk.  She had poor sitting posture (see Figure 1) which created difficulty in sitting for more than 15 minutes without low back pain.  Her seated posture also limited her ability to look up and down from the blackboard which added to her academic difficulties.  In addition, her poor standing (see Figure 2) and walking posture made standing for more than 15 minutes painful and she was unable to walk for more than a few blocks without fatigue.  Sindy had additional difficulty standing on one foot, going up or down stairs without holding on to the rail and had difficulties with jumping, skipping and hopping.  All of this made joining activities on the playground at school challenging and required modification of home activities.

Sindy also had frequent complaints of headaches and neck/shoulder pain due to poor posture while writing or keyboarding at school.  These complaints occurred once or twice per month, requiring the need to leave school so she could be have heat and pain medications at home.  She also experienced frequent sprained her ankles on uneven ground bi-monthly, also resulting in the need to leave school for treatment.

Sindy’s primary strategy for creating stability in her trunk was breath holding during movement and prolonged tasks (sitting, writing).  It was observed that this breath holding also further contributed to her sensory processing difficulties (as breath holding increases the fright/flight/fight activity of the sympathetic nervous system).  This also tended to worsen her anxiety.

Figure 1

Figure 2

 

Intervention:

Treatment was provided over a series of 1 hour sessions.  The sessions varied from once every 2 weeks to once per month over 4 months.

Dynamic Core for Kids is based on creating the best function of the inner core muscles (which stabilize the spine and pelvis before movement begins) in partnership with the outer core muscles (which are responsible for movement).  We initially accomplished this for Sindy by teaching proper breathing before she began to move to activate the inner core muscles through diaphragm activation; the phrase “blow before you go” was an important cue. She was able to fully utilize her diaphragm by creating neutral ribcage and pelvis position through the use of pillows in lying and a wedge in sitting.

Results:

Treatment resulted in Sindy achieving and maintaining more neutral posture in sitting and standing (Figures 3 and 4).  A seating support (wedge or properly positioned office chair) continues to be utilized to maintain proper alignment and build endurance during home and school activities that required the prolonged sitting position.

Figure 3

Figure 4

Sindy has not complained of neck pain or headaches since her posture has improved.  Her balance is much better and there have been no ankle sprains since treatment with Dynamic Core. Her Core breathing is now used as a management technique for her anxiety.  It is possible for her to take longer walks and she now enjoys swimming as a regular recreational activity. Overall, she is more confident in her movement.

 

 

The Dynamic Core for Kids approach was co-created by Shelley Mannell PT and Julie Wiebe, PT.  For more information please go to Shelley’s website/blog at www.heartspacept.com or to Julie’s website/blog at www.interiorfitness.com.

Photographs used with permission.

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