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Boston — Balance deficits, and delays in head righting and protective reaction become apparent as children begin to sit, stand and walk, but for lack of a clear understanding of these issues, parents often will state: "My child is clumsy," according to Darwyn Bartsch, PT, DPT, who gave a presentation on the topic at the sixth annual Cross Country Education Rehab Summit Conference and Expo, held here July 26-28.

A child with these issues does not learn from the pain associated with balance errors, and people may laugh because his or her actions seem humorous, Bartsch said. "What I want you to understand is that clumsy hurts. It hurts the child and it hurts the parents," he said.

Therapists should listen for clues in a child’s family’s descriptors, Bartsch said. They may include information about how and when the child falls, problems with running or standing still, and injuries sustained. "If we’re not looking closely for the components, we can easily miss it," he said. "The clues parents give are often in passing."

These children may have low or high tone issues, joint laxity, a history of torticollis, or hearing or visual impairments, Bartsch said. Coordination impairments may stem from diagnoses such as Down syndrome or Pierre Robin syndrome, "however, there may be no given diagnosis at all," he said. "There’s no obvious reason for the child’s clumsiness."

Foundation

"All balance has to do with some measures of the center of gravity and base of support," Bartsch said. The relationship between these two is the foundation for all motor skills, he said. "If we cannot get them to manage that center of balance and base of support, their ability to progress is almost zero because of the safety components tied to it."

In normal gait, the center of gravity remains between footprints, however this child is unable to manage the center of gravity and it frequently drifts outside the base of support, resulting in a fall, Bartsch said.

Balance is achieved through the body’s motor, sensory and cognitive systems working in unison, Bartsch said. "In the children we work with, these systems are not working together," he said.

Variability in movement control causes inconsistent outcomes, which can result in falls and other failures, Bartsch said.

Observation

A child’s head righting should be observed to determine whether it is occurring before the center of gravity drifts out of the base of support, or even occurring at all, Bartsch said.

Then protective reactions need to be examined, he said. "If a child does not have good protective reactions, we have to teach them — it’s an absolute must," he said. "The challenge is convincing the parents we need to backtrack completely."

Are protective reactions occurring with head righting or instead of head righting? If they are happening with head righting, it means the child is preparing to fall but struggling to complete the task. If they are happening before head righting, the child is simply preparing for a fall, he said.

Is the child seeking support — such as grabbing, sitting or collapsing — rather than engaging in protective reactions? The therapist should "provide support as long as the task they are performing is relatively correct," Bartsch said.

Feedback during a task must be instantaneous for a child to learn, Bartsch said. "Verbal cues require time to process and respond," he said. "I use 'yes’ and 'no’ commands." He suggested combining those with tactile cues, such as squeezing the hands.

When in the home environment, make sure distractions are minimized — turn off the television and have siblings leave the room, he said.

Video recording and photographing of children during observation can be helpful, he said. "If we’re working with a kid and can’t figure out what’s happening, we do a video [or] snapshots," he said. "If I did not have video, I wouldn’t have caught [certain problems]."

Postural control and motor assessments should be routine procedure for hearing impaired children, he noted.

Activities

Therapists need to incorporate activities that help build protective reactions sideways, forward and backward, Bartsch said. "If there’s no regression, I’ll put her through the pattern and repeat, and put her through the pattern and repeat," he said.

Head righting can be practiced either sitting on the floor or on a therapy ball, Bartsch said. Start with small oscillations, keeping the head within the base of support, giving the child time to correct. "As soon as they do the right thing, we do instant feedback by bringing them back to center."

In standing head-righting activities, start with a wide base of support and give the child additional support, then progress to decreasing support, Bartsch said. As the base of support is narrowed, offer the child more support again, then decrease again, he said. "When they go wrong, they go wrong really fast," Bartsch said. "We have to be able to anticipate what is going to happen."

Moving on to dynamic tasks, assist the child as needed to correct the pattern, correct control and help decrease errors, he said. Initially, have the child walk between lines about a foot apart with assistance, then decrease assistance. "Lots and lots of support to get her to do that correctly," he said. "The whole point we’re interested in is managing their center of gravity."

As the child improves, narrow the width, then have the child walk on a curb about 8 inches wide, he said. "It’s elevated enough it gets their attention."

Not a lot of equipment is needed for these tasks, Bartsch noted. "I bring none of my own supplies other than the curb. Even then, I try and get families to get their own step," he said. •

Natasha Emmons is the editor.