We continue our series on checklists for yearly Pediatrician check-ups (click here to see the checklists for the 1-year visit, the 2-year visit and the 3-year visit). Pediatricians have a set of developmental red flags, but these only hit the “big-bad-uglies” as we like to call them, including the following: Can you understand everything your child says? Does your child fall excessively? Is he feeding himself? These red flags are very specific, meaning a child who exhibits these red flags would be identified for services, but not very sensitive, meaning many children who would benefit from therapy services are missed. To help bridge the gap between Pediatricians’ red flags and children who need therapy services, I have put together a checklist of things to discuss with your Pediatrician at your child’s 4 year check-up.
At 4 Years Your Child Should Be Able to Do the Following:
Gross Motor Skills
Places one foot on each stair, while going up and down stairs without handrail use
We continue our series on checklists for yearly Pediatrician check-ups (click here to see the checklist for the 1-year visit and the 2-year visit). Pediatricians have a set of developmental red flags, but these only hit the “big-bad-uglys” as we like to call them, including: stutter, go up and down stairs by themselves, or answer and ask “yes or no” questions. These red flags are very specific, meaning a child who exhibits these red flags would be identified for services, but not very sensitive, meaning many children who would benefit from therapy services are missed. To help bridge the gap between Pediatricians’ red flags and children who need therapy services, I have put together a checklist of things to discuss with your Pediatrician at your child’s 3 year check-up.
At 3 Years, Your Child Should Be Able to Do the Following:
Gross Motor Skills
Pedals a tricycle
Catches a ball thrown from 5 feet away
Jumps forward at least 24 inches, with both feet leaving the ground at the same time
Stands on 1 foot for 3 seconds
Walks up stairs with 1 foot on each step
Fine Motor Skills
Draws circle, horizontal lines, and cross, with demonstration
Strings small beads
Opens screwed top container
Pulls up pants and puts on coat independently
Increases word production to >300 words
Combines 3 word phrases
Starts to understand differences between opposites
Building off of last month’s 1 year check-list for Pediatrician check-ups, we bring you a check-list to look at prior to your child’s 2 year old check-up. Again Pediatricians have a set of developmental red flags, but these only hit the “big-bad-uglys” as we like to call them, including the following questions: does your child get frustrated when trying to talk, can he or she jump or attempt to jump, did your child walk by 18 months. These red flags are very specific, meaning a child who exhibits these red flags would be identified for services, but not very sensitive, meaning many children who would benefit from therapy services are missed. To help bridge the gap between Pediatricians’ red flags and children who need therapy services, I have put together a checklist of things to discuss with your Pediatrician at your child’s 2 year check-up.
2-Year Check-Up Red Flags:
Gross Motor Skills
Runs forward 10 feet, without a loss of balance
Jumps in place, jumps forward, and jumps down from a step
Walks forward, backwards, and sideways independently and without a loss of balance
Walks up and down a set of stairs, using a handrail
Kicks a ball forward 3 feet
Fine Motor Skills
Turns pages of thick page book, 1 at a time
Stacks 5 cubes
Draws vertical lines given demonstration
Takes off button-less clothing and socks independently
Begins saying 2 word phases and 2 word questions
Increases vocabulary to saying >50 words and understanding >300 words, with new words added every week
Answers “yes or no” questions
Points to objects named
Speech should be understood at least 50-75% of the time by a familiar listener
When a child attends a physical therapy evaluation for a developmental concern (e.g. delayed walking), an orthopedic injury (e.g. sprained ankle), or a neurological condition (e.g. cerebral palsy), the pediatric physical therapist makes important clinical observations as part of the assessment process. From standardized tests, to medical history, to visual inspection, the physical therapy examination process is multi-fold and complex. While Manual Muscle Testing (MMT) is a tried and true method of measuring strength discrepancies in orthopedic and neurological cases in adults, isolating and grading muscle strength in children can be tricky and harder to standardize across practitioners and patients.
So how do physical therapists test for muscle strength in children?
Most of the strength testing is done through observation. Instead of testing isolated muscles, physical therapists look for movements across muscle groups. To know if a baby has the proper strength to explore his environment, we look for specific muscle actions during motions done against gravity. For example, can an 8 month old baby push himself on to hands and knees? Can a 6-month-old bring his feet to his mouth? Can a 3-months-old tuck his chin when pulled from a lying position to a sitting position? What physical therapists are looking for is 1) the ability to make certain movements against gravity at appropriate stages of development, 2) symmetry between side of the body to ensure proper growth, and 3) making sure the baby isn’t just compensating for a weak body part by using another muscle group to move inefficiently.
When testing muscle power of older children, symmetry of movement and absence of compensatory patterns are still important indicators of age-appropriate strength. While the literature has not agreed on a minimum age for MMT to be used on children (the advised range is between 5-10 years of age), the general consensus is that the child should have the language and cognitive development to follow the MMT instructions. When testing isolated joint actions and muscle strength, the examiner has to apply an external force to the muscle group being tested. In young children, the levels of resistance applied must match the child’s size and weight. Just like with babies, functional tasks are a great way to test muscle strength and power in a young child, or a child with developmental difficulties. For example, being able to perform sit to stand or squat to stand without deviations would suggest appropriate muscle strength and control of lower body muscles such as the quadriceps, hamstrings, and the glutes. Being able to perform stair climbing without needing a rail or without knees buckling would suggest sufficient lower body muscle power as well.
Adolescents can be tested using the adult standardized method of manual muscle testing. Depending on the scale used, examiners can give the muscle one of 10 grades and descriptions for strength, such as poor, fair, good, normal, etc. Because MMT is a standardized process, consistency of testing is critical. Muscles are thoroughly tested in gravity-lessened and against-gravity positions. Testing of the unaffected side is also important, to attain a normal baseline for the person being tested.
For further reading on MMT grades and procedures, consult the charts listed in the references provided. Manual Muscle Testing is used by physical therapists, physiatrists, orthopedists, and neurologists alike. It is an important part of the physical examination process. While used primarily in adults, children as young has 4 years of age can be tested using this method.
References: Kendall, F.P., E.K. McCreary, and P.G. Provance, Muscles: Testing and Function, in Posture and Pain. 1993, Baltimore: Williams & Wilkins. Dutton, M. Principles of Manual Muscle Testing, in Orthopedic Examination, Evaluation, and Intervention. Available at http://highered.mheducation.com/sites/0071474013/student_view0/chapter8/manuaul_muscle_testing.html. Accessed July 6th, 2014. Palmer, M.L. and M. Epler, Principles of Examination Techniques, in Clinical Assessment Procedures in Physical Therapy, M.L. Palmer and M. Epler, Editors. 1990, JB Lippincott: Philadelphia. p. 8-36.
Children develop and improve their gross motor skills significantly during their early school years, between three and ten years of age. A lot of gross motor development occurs at school while playing at recess or doing activities in gym class. School offers the opportunity to recognize if a child needs extra assistance from a physical therapist in expanding or improving their gross motor skills.
Here are some tips for teachers that will help determine if a child would benefit from physical therapy:
The child prefers to sit and play instead of run or participate in gross motor activities during recess or gym class.
The child has difficulty jumping, skipping, or galloping when compared to their peers.
The child has an atypical gait pattern (for example, they walk on their toes or they are “knock-kneed”)
The child prefers to w-sit (with their knees bent, feet by their bottom, and bottom on the floor) instead of crossed-legged on the floor.
The child frequently trips, falls, or bumps into objects.
When walking up and down the stairs, the child does not alternate their feet, instead placing both feet on each step.
The child is unable to kick a soccer ball.
The child is unable to catch or throw a playground ball.
The child runs significantly slower than his peers or has difficulty running for more than one minute.
The child complains of pain or tightness in their ankles, knees, hips, or back.
If you see any of these characteristics in children at school, they may benefit from a physical therapy evaluation. Without fully developed gross motor skills, a child is going to have difficulties keeping up with their peers during recess or gym class. It will also affect their ability to participate in gross motor games and sports. Also, it is important to note that many children will exhibit the above behaviors and may or may not require physical therapy (PT) intervention therefore it is important to consult with a PT first.
https://nspt4kids.com/wp-content/uploads/2016/05/nspt_2-color-logo_noclaims.png00Leida Van Osshttps://nspt4kids.com/wp-content/uploads/2016/05/nspt_2-color-logo_noclaims.pngLeida Van Oss2012-09-26 11:00:172014-04-26 17:13:5310 Signs at School Suggesting a Student May Benefit from Physical Therapy
Coming to a physical therapist for your child for the first time can be an overwhelming and confusing experience – but it doesn’t have to be! Here at North Shore Pediatric Therapy we have outlined the most important information to know before you go to the pediatric physical therapist for the first time.
Paperwork: Although no one enjoys filling out form after form, this information is essential to the therapist and office staff. Please remember to bring the following with you at your first appointment. This information will be emailed to you by the family-child advocate before you come in.
Copy of your physician’s prescription for physical therapy. It is imperative that we have this on file before any ongoing treatment sessions.
Your child’s past medical history. We will ask questions concerning his or her gross motor milestones and at what ages these were achieved, as well as birth history, pertinent family health history, educational history and general information about your child’s motor, language and social skills. Also if your child has visited a therapist before and you have documentation from these visits, we would be happy to make a copy of those as well.
A clear picture of your availability for future appointments. We will do our very best to make all future treatment appointments at the initial evaluation.
Equipment: It would be helpful to us and your child if you bring a few things along with you.
For infants and younger children:
A toy that he or she responds to and enjoys can be used during treatment. This helps us transition the child to the new environment and is good for tracking skills.
A onesie to wear during the treatment sessions. At the evaluation we will observe the child moving without clothes on (except for the diaper) to observe his or her muscles and general tone.
A blanket can be more comfortable for the children to move around on. If you don’t have one don’t worry, our treatment mat is soft and secure.
A pacifier can help to soothe your child
A bottle or source of food might help if the child becomes hungry. He or she will be working hard and might become hungrier than normal.
A change of diapers is never a bad idea!
For toddlers and older children:
Dress your child in comfortable clothes that are easy to climb, jump, roll, crawl and move in.
Wear athletic shoes and socks to the appointment. We will complete most exercises without shoes on in order to accurately assess balance and movement skills. However, it is helpful for the therapist to see what footwear the child wears and if additional recommendations are warranted.
Assess gross motor milestones (i.e. rolling, crawling, running, jumping, skipping)
Discuss treatment plan and what you should expect out of therapy.
Plan functional short term and long term goals for your child.
Standardized testing is usually completed in order to get a baseline measurement for your child. These tests allow us to measure your child against his or her peers, and create realistic projections for what we can expect to achieve through therapy.
The physical therapist working with your child will be able to answer all of your questions pertaining to his or her diagnosis at the first appointment. Any questions that come up after that initial evaluation can be answered before, during or after future appointments via email, phone, or in-person conversations. Thank you for taking the time to read this and be prepared. We look forward to meeting you and your child!
* This article was also written by Adele Nathan, Student Physical Therapist at North Shore Pediatric Therapy