Not sure if your child has low muscle tone, also called hypotonia; check out this post:
I always consider getting the biggest bang for my buck. When children come to see me they don’t have time to do every possible exercise that I may come up with to address a number of different areas. So I look to do activities that are going to address many areas at once, always thinking how it will stimulate the brain to grow and develop.
Positions that are important for your child to conquer:
Tummy time. Using a ball is more fun, and serves the purpose of stimulating their inner ear (vestibular system) and vision. Gently rock your baby back and forth and side to side, try a circular pattern, vary the speed but make sure you are holding them safely on the ball, and you have a good grip on the ball yourself.
The photo below shows a child lifting their head and arms up nicely. This is fine if done some of the time. It is not fine if this is all your child does, because it does not work their tummy muscles. While this child does not look like they have low muscle tone, in babies with low muscle tone we want to see them pushing up with their hands.
The child pictured below can now play because he can lean one hand on the supporting surface and reach with the other. Once they can do this they will spend more time on their tummy and you won’t have to work so hard.
This position is great for your 6-10 month old, it prepares them for crawling.
Check out other ideas for teaching your child to crawl with my three part series on crawling. Don’t let your child with low tone avoid crawling, it is one of the best skills they can learn and will develop their brain and body musculature in many ways.
Equipment that might be needed:
Hip Helpers: Are useful for the child with low muscle tone who has excessive hip mobility. If your child’s hips are floppy and they can do a split or straddle, then these shorts are needed to tighten up their muscles and joints. The shorts will help them strengthen their body and trunk muscles, because their base of support will be smaller as they will have to long sit, or side sit. They will not be able to frog sit or W sit. I don’t recommend wearing them all day, 2-3 hours in the morning and 1-2 in the afternoon. Wearing them for half of their standing time for 4-6 weeks. Once they start to walk fairly well, they should not wear them. These are inexpensive and easy to order.
Classic TLSO (thoracic lumbosacral orthosis) by SPIO : See below. This is a type of compression garment that will give your toddler sensory input, while also giving them some support. The sensory (pressure) input helps give them a sense of where they are in space so they feel more confident moving, and are less clumsy. The support gives them more endurance to stick with a task, or play activity. While the SPIO can be measured and ordered by you, if you go to an orthotist who works with children, he or she will be able to bill your insurance company. The garment can be worn all day, but generally it is recommended to be worn for 2-4 hours once or twice a day. In this way your child will not accommodate to the feel and start to sink into the support, but will stay stimulated by it. Some children need more support than this garment will provide. Your child’s care givers- orthopedist, physiatrist, physical therapist, may recommend one of the following garments as seen on this site, instead: Complex Child
Sensory stimulation that is needed:
The following ideas are to help your relaxed happy baby who is totally content sitting and getting you to do all their work- to change- and become the exploring machine they need to be. These techniques tap into their brain, and important sensory systems ( vestibular and proprioceptive), and will actually improve your child’s muscle tone, and stimulate them to move.
Swing, Rock and Roll
Karen Pryor DPT taught this technique at a course I attended recently. I suggest to parents to do this a few times a week. I am pleased with the changes I see in my patients who’s parents are doing this.
I would not do this technique if I suspected my child had seizures, hydrocephalus, microcephaly, any cervical or cranial problem.
whole body massage. This was also taught by Karen Pryor. This is not a “gentle put you to sleep massage”. This is one to increase alertness, attention, engagement, and body awareness. Gently but firmly with brisk strokes in a downward motion go over your child’s arms, legs, and the front and back of their body. An image I like to use: “After a day at the beach I need to brush the sand off my babies skin.” You can do this daily.
massage vibrator: For infants over 6 months. This will stimulate their muscles and help with body awareness. Generally children with low muscle tone enjoy having a vibrator run up and down their back, arms and legs. Avoid their bellies and heads. This is a fun toy, your baby can grasp it; and feel the vibration up to their shoulders. As toddlers they can learn to turn it on themselves and give you a massage! Here is an image of one that is inexpensive and easy to find at a drug store. I like this general shape because it is easy for young children to hold.
Music: Did you know that music stimulates all parts of our brain? So enjoy singing, to your baby and child. Hold your baby and dance with him as you sing. Or make up arm movements and gently move them as you sing “Itsy bitsy spider”, or ” The wheels on the bus”. Nursery rhythms are helpful for language development. Playing music in the car and in your home, is a great way to pass the time, and develop a family culture. Classical music is said to develop our brains in many ways. So mix it up and enjoy yourself.
There are a number of walking harnesses out on the market today. They can help you as a parent not strain your back bending over to hold up your toddler. And if your child has low muscle tone, it is a good idea to avoid holding their arms in the overhead position as seen below:
Their shoulder girdle may not be strong and stable enough to be supportive for the rest of their body. And we don’t want to stretch out their little joints.
I would not use a harness on a child under ten months, and in general I do not recommend early walking (under eleven months) for an otherwise typically developing child. Remember the goal is to have them crawl for at least 2 months before walking.
I do recommend shortening the time when your child starts to pull to stand on their own, and cruise- and their actual first steps. If they have been cruising for more than two months and they are 14 months old, then I would increase the amount of time they are on their feet and walking. The biggest reason is that many children won’t take off with their language until they have mastered walking. Why is this? There aren’t enough hours in the day, nor energy in a child, to focus on two big skills at once. Developmentally there should be a burst of language around 18 months. So it is nice if your child is a confident walker by then.
Below are a number of Harness options and the pros and cons of each
A&S Creavention® BabyWalker Baby Walking Protective Belt Carry Trooper Walking Harness Learning Assistant Version 2.
The bar across the top is easy to hold and you can control your child’s body easily. You can help them to move forward or encourage them to go a bit slower, or help them not lean so far forward… you get the idea. You could hold the bar with one hand for a second if you needed to reach something.
The chest strap can end up pulling up under your child’s arm pits and raise their shoulders up. This position would be uncomfortable, and not the alignment of their body that you want for your child as they are learning to walk.
This design with two straps may be hard to coordinate with your arms if your child is unstable.
The Pro of the following design is the pelvic support will help control your child’s lower body somewhat. The chest straps may give enough support to the upper body for your child. And it has a bar which as we noted might be easier than straps for you to manage.
The Con: Because children at this age are top heavy, it leaves a good amount of their body unsupported above the axis of the harness. This may be fine for many children. If your child needs a fair amount of upper body support and they try to lean on the chest straps they may not feel secure.
Here is a video of a Toddler with Mom using the first type of harness.
When his parents first tried it a month earlier, we decided he was not ready to use the harness. He needed more support than the harness gave him.
Here are the skills he had that told me he is ready to use the harness:
Crawling- and in this case up an incline wedge:
Playing on hands and knees:
Pulling to stand on a vertical surface
Here he is after two weeks of using the harness with Mom and Dad; as well as doing lots of climbing activities at home with his parents. He is stronger, faster, more confident and well on his way to be an independent walker.
Here is another technique that can save your back: A home made push toy!
Pushing a kitchen or dining room chair across linoleum or wood floor will build up their upper body strength and give them practice walking. Hold the back of the chair and gently help them move it forward- for them- backward for you. Have a toy on the chair like a piano.
For more ideas on helping your child learn to walk check out this blog:
Just a heads up on the Boston Abilities Expo taking place at the Convention and Exhibition Center- Hall C. September 16-18.
Registration is free.
This is a great resource for families and professionals. From their web site:
” Every event opens your eyes to new technologies, new possibilities, new solutions and new opportunities to change your life. Where else can you discover ability-enhancing products and services, play a few adaptive sports, learn new dance moves, attend informative workshops and only scratch the surface of what Abilities Expo has to offer? Register for free today.”
Hope to see you there!
So you realize that your child is a toe walker?
What do you do next?
It is a movement disorder, with a number of factors to consider.
The first issue is to stretch the heel cords, and hip muscles, while strengthening the opposite muscles.
The next step is to determine why your child has chosen an inefficient way to walk. More than likely it is related to one or both of the following: weak core or sensory processing disorder.
The last steps should involve gait training and considerations of casting and bracing.
If your child is weak, then stiffening their whole body by going up on their toes can help them maintain higher muscle tone, and recruit more muscles to work for them.
The solution is to strengthen the core muscles, then retrain the walking pattern. Your PT has many ways to do this with fun exercises, use of gym balls, scooter boards, and a home exercise program.
For retraining walking your therapist may use: theraband, treadmills, obstacle courses, hurdles etc.
Here is a fun “tool” to use for a child under the age of 7 or 8 . I found these duck feet at a toy store. Swim flippers cut down a bit, or Dad’s big shoes would work as well.
The duck feet are causing this child to take higher, longer steps.
She can not walk on her toes with these on, so she is getting her heel in contact with the floor. I would want these to be worn for 30-60 minutes a day.
If your PT feels your child has sensory processing issues she will address the areas in a number of ways. Your therapist should evaluate your child’s tactile, proprioceptive, visual and vestibular systems- all parts of our sensory systems to determine what senses may be behind in development and causing your child to want to walk on their toes.
If your child has tactile defensiveness; then placing their whole foot on the floor is a challenge. This needs to be addressed before they can be convinced to change their walking pattern.
Some activities might include: Stomping/marching in bare feet, Placing feet in a bin of sand, rice or pasta, giving their own foot a massage with oil, then a towel.
Your child have diminished proprioceptive input- which goes hand in hand with low muscle tone and a weak core. So bouncing along stimulating their inner ear- vestibular system-tells their body where it is in space. (Because their muscle and joint receptors aren’t giving them enough information.) In the picture below, alot is going on. I have my little friend in a semi squatting position- resting on a stool- reaching forward is giving pressure into her left foot. The right foot is getting input from a mini back massager I got at the local drug store; her Mom is trying it out. They will use it at home nightly for 5-10 minutes on each foot. They will do these two activities separately.
If your child has delays in functional vision, than they may be off balance as they walk. To work on vision you can check out my blog on vision and bike riding, the activities are appropriate for toe walkers. Many children who toe walk are cautious on stairs ( could be depth perception), and not able to catch a ball ( maybe lack of visual convergence).
The vestibular system may be delayed. This is a complex system that works closely with vision and assists in maintaining balance. Your therapist may use slides, swings, trampoline, scooters, balls, and tie these activities into a visual activity at the same time- scanning, holding gaze etc.
And lastly balance should be assessed and addressed if it is a problem. Your therapist may use a balance beam, rocker board, half foam roller, dyna disc. They may have your child do activities on one foot, or build an obstacle courses.
Home exercises must be done to carry over gains made in therapy.
If your child has very tight muscles, or has been toe walking for years, they may need further intervention.
It is important to have a Pediatric Orthopedist work with you, your child and your PT to determine what next steps are needed.
If your child’s ankles are very tight a cast may be put on for a week or two to stretch out the muscles. This is painless, but a significant inconvenience.
Resting casts may be fabricated, to be worn each and every night to help stretch the ankle, and or keep the ankle stretched out after the casting.
Other types of night splints might be custom made of plastic, or a dynamic system like the Ultra Flex Bracing System.
Once the ankle muscles have gotten looser, it is important to consider what assistance might be needed to break the toe walking habit.
Orthotics and Bracing may be needed. A starting point might be a metal insert usually fabricated by an Orthotist, which inhibits the ability to toe walk. It is a piece of aluminum that is cut to be the size of the sole of the shoe, it goes under the insole of the shoe. This makes it very hard for many (but not all), children to go up on their toes.
If this does not work, then the next step is to have a brace made by an orthotist which will help retrain the correct walking pattern. Something similar to what is shown in this picture. It is to be worn most of the day. Consider how long your child spent walking on their toes; they need 6 months to a year to change their walking pattern. Some children need more time, some less.
These two are hinged;- so your child can learn to flex their upper leg over their lower leg and foot.
This can all seem overwhelming for what appears to be just a bad habit.
But long term toe walking can lead to the heel cords being so tight, that children have trouble, walking, running, going up and down stairs, and squatting. It can lead to ankle, calf, and knee pain. It can cause tripping, and falling, as well as not keeping up with their peers on the playground, or with sports.
Talk with your pediatrician about your concerns and consider scheduling an appointment with a pediatric physical therapist, and a pediatric orthopedist. Having the habit broken at age: 2, 3, 4 or 5 years, is much easier than at 10 or 12 years of age.