Physiotherapy Home Programmes

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Physiotherapy Home programmes for children with motor delay Sarah Crombie

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First published in 1997 by Winslow Press Ltd, Telford Road, Bicester, Oxon OX6 OTS, UK

Copyright © Sarah Crombie, 1997 All rights reserved. The whole of this work including all text and illustrations is protected by copyright. No part of it may be copied, altered, adapted or otherwise exploited in any way without express prior permission, unless in accordance with the provisions of the Copyright Designs and Patents Act 1988 or in order to photocopy or make duplicating masters of those pages so indicated, without alteration and including copyright notices, for the express purpose of instruction and examination. No parts of this work may otherwise be loaded, stored, manipulated, reproduced, or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, or by any information, storage and retrieval system without prior written permission from the publisher, on behalf of the copyright owner. 003-2770/Printed in the United Kingdom British Library Cataloguing in Publication Data Crombie, Sarah Physiotherapy home programmes for children with motor delay 1. Cerebral palsy - Physical therapy 2. Cerebral palsied children - Home care I. Title 618.9'2836'062 ISBN 0 86388 171 8

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CONTENTS Section one Personal Information About Your Child Section two Home Exercises Section three Other Information on Development

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ACKNOWLEDGEMENTS I wish to thank the physiotherapy staff at the Wilfrid Sheldon Child Development Centre, especially Rowenna Hughes, Inge Gregorius and Helen Farmer, for their encouragement and assistance in the development of this material. Thanks go also to Jane Macer, Irene Sclare, Caroline Griffiths and David Crombie for their contributions and to Jonathon Evans and Gail Thurley for the illustrations. Sarah Crombie is currently working as a superintendent physiotherapist for the Royal West Sussex Trust at St Richard's Hospital, Chichester and in the community. This involves the treatment and management of children with developmental delay and neurological problems, working closely with their families and carers at home, the nursery or in school. Earlier in her career Sarah worked as a clinical physiotherapist at the Wilfrid Sheldon Child Development Centre, London and at King's College Hospital, London. When working as a senior physiotherapist at the Centre she was awarded a grant for a two-year project whose purpose was to extend and develop physiotherapy services in the community. During this time a further grant was obtained to develop and pilot the programme which is the core of this manual. Sarah is at present undertaking a Master of Science degree in rehabilitation research at Southampton University.

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INTRODUCTION The Physiotherapy Home Programmes for Children with Motor Delay has been designed for use by physiotherapists to compile personalized home exercise and management programmes for children with motor delay or dysfunction. An illustrated programme can be devised to meet the individual needs of the child and made easy to read and use at home by parents or by teachers and other staff caring for the child. This programme can be readily revised and updated as necessary. The manual is divided into three sections: Section 1 comprises information sheets on which to enter personal details about the child, important information related to therapy, individual goals for therapy, equipment lists and so on. As these are individual sheets, they can be selected and tailored to meet the specific needs of the particular child. Section 2, the major part of this manual, contains diagrams with a simple text illustrating exercises which may be continued at home or at school, as an adjunct to any treatment and management programme. The exercises would need to be carried out under instruction from individual therapist. Section 3 provides further information on the areas of play and communication. Overall, the manual will serve as an important source of information and a reminder of exercises to continue at home. It promotes easy communication between parents and others involved in caring for the child and ensures that they all work together to share the same goals in the child's therapy and everyday activities.

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SECTION 1 PERSONAL INFORMATION ABOUT YOUR CHILD

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SECTION 2 HOME EXERCISES

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A: Relaxation Techniques A1: Relaxing baby on your lap

__ Lay baby on your lap or on the floor. Make sure the arms are forward and not curled up under the body. __With your hand gently pressed down on baby's bottom, slowly rock the hips back and forth. __This will help to relax your baby generally, and is always a good exercise to start with.

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A2: Relaxing baby

__ Hold baby on their side with their back against your stomach. __ Put one hand under the shoulder, one on the hips. __ Hold the shoulders still and slowly twist the lower part of the body away from and towards you. __ This is a good exercise to do before others as it helps to relax the body generally.

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A3: Relaxing the body

__ Lay the child on your legs, keeping the body as symmetrical as possible, that is, with the head in the middle. __ Slowly lift and lower the hips to help them relax. __ Try lifting one hip only so the body twists a little, and then lift the other side. The shoulders should remain still. __ The legs will become more relaxed as you do this. Turn them out to help this. __This is a good exercise to relax your child before doing others.

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A4: Relaxing the body by moving the legs

__ This exercise should be done when the hips have already been relaxed. __ With one hand, hold the knee to keep the leg straight. __ With the other hand, hold the foot bent upwards, that is, as if the child is standing on it. __ Keep the leg turned outwards and slowly move the whole leg up and down in the direction of the opposite shoulder. __ The leg should relax and so relax the hips more. __ Do the same with the other leg.

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A5: Relaxing over a ball (holding legs)

__ Keep the child's arms forwards and place your hand on their bottom to steady the child on the ball. __ Keep the legs apart and turned out, that is with heels towards each other. __ Slowly rock the child's bottom from side to side. __ Gently stretch one leg out and then the other. __Carry on until you feel your child relaxing.

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A6: Relaxing over a ball (holding arms)

__ Hold the child's arms at wrists or elbows. __ Keep their hips and legs steady using your body. __ Keep their arms turned so that their palms are towards each other. __ Slowly lift the top half of the body and twist to one side and the other. __ This will help to relax the body.

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A7: Relaxing your child in the sitting position

__ Sit your child on your lap facing away from you. __ Hold across the child's chest and under the shoulders with one arm and keep the hips steady with the other. __ Slowly twist the shoulders and top half of the body to one side and then the other. __ This will help relax the body and is a good exercise to do whenever your child feels stiff.

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A8: Stretching arms forward

__ Hold the arms above the elbows. __ Turn the arms out from the shoulders first and move your hands down over the elbows. __ Gradually stretch the arms out towards you, turning them out at the same time, that is with palms facing upwards.

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A9: Opening hands and fingers

__ By first straightening and turning out the arm, you make it easier to stretch out the thumb and then the fingers.

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A10: Relaxing a tight arm

__ Hold the arm at the elbow and wrist. Keep it straight. __ Turn the arm outwards and keep the wrist flexed upwards. __ Slowly move the whole arm up towards the shoulder, as if shrugging the shoulder, and then down. __Carry on until the arm begins to relax. __ This exercise can also be done when your child is sitting up. When the arm is more relaxed, it should be brought forwards onto a table where your child can see it and move it more effectively.

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A11: Stretching a tight arm

__ Hold the arm at the elbow and wrist. __ Lift it up and gently straighten it out, turning the arm outwards as you do so, that is with the palm to the ceiling. __ Lift the whole arm up above the head, opening out the thumb and fingers.

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A12: Helping to separate the legs

__ When trying to part the legs, for example for nappy changing, do not hold the ankles but the knees. __ Turn the legs outwards as you do this.

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A13: Relaxing the toes

__ Put your fingers under the toes and stretch them out. __ Lay them down flat. __ Keep doing this whenever the toes curl up, as this is often a sign of the whole body getting tight.

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B: Lifting and Carrying B1: Carrying baby curled up

__ Carry your baby in a curled up position with the shoulders forward and the hips bent up. __ Support behind the neck and shoulders, not just the head.

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B2: Carrying baby on your hips

__ Carry your child as shown, with their legs around your hips. __Support them under their bottom.

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B3: Carrying in the 'aeroplane' position

__ Carry the child with your arm between their legs and your hand under the chest or, if they are bigger, with one arm under the chest and shoulders and the other keeping the legs up. __ Try to keep their arms and legs turned out.

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B4: Carrying baby facing away from you

__ Carry baby with their back against your front, legs bent up. __ Support them under the thighs __ Keep their legs apart.

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B5: Carrying your child to help strengthen the back

__ Hold your child at their knees. __ Keep the legs apart and turned outwards. __ Encourage them to hold their bodies up, with you only supporting their bottom with your chest.

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B6: Lifting your child up from the floor (1)

__ Kneel down by your child. __ Curl them up as you lift them from the floor. __ Keep them close to your body. __ Put one foot forward to stand up. __ Keep your back straight as you stand up.

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B7: Lifting your child up from the floor (2)

__ Turn your child over onto their front before you lift them up. Put one arm between their legs to keep them apart. __ Hold your child close to you and slowly stand up. __ Remember to bend your knees, not your back.

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SECTION TWO HOME EXERCISES

B: Lifting and Carrying B8: Lifting your child up from the floor (3)

__ Place one arm between the child's legs to keep them apart. __ Roll the child up and towards you, curling them up as you do so. __ Lift them onto your lap and then stand up.

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C: Prone Activities C1: Lying on their front to play (1)

__ Encourage your child to lie on their front to play and to take weight on their forearms. __ Put a toy in front to encourage your child to lift up their head.

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C2: Lying on their front to play (2)

__ Encourage your child to lie on their front to play. __ Roll up a towel to put under the chest if necessary. This keeps the arms forwards so that the weight is on the forearms. __ Put a toy in front to encourage your child to lift up their head.

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C3: Lying on their fron to play (3)

__ Lay your child on their front to play. __ Encourage them to rest on their elbows by putting gentle pressure down through their shoulders. __ Play with a toy in front to encourage them to lift their head up.

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C4: Laying baby prone on you

__ This is a good position to help encourage your baby to lie on their front and to lift their head up.

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C5: Play over legs

__ Lay baby over your lap to play. __ Make sure the hands are open and taking some weight.

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C6: Lying on their front to play (straight arms)

__ Put a rolled up towel or therapy roll under the chest. __ Encourage your child to play in this position with their elbows straight. __ Later on they can be encouraged to put more weight on their hands and start to reach out. Keep the hands shoulder distance apart.

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C7: Laying the older child on their front

__ Encourage your child to play in this position. __ Keep their arms forwards and legs apart (use a towel or cushion for this). __ You can use a wedge instead of a roll to help your child lie in this position.

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C8: Over a roll with weight on the arms

__ Place the child in the position shown. __ Hold the front of the knees, turning the legs out. __ Encourage your child to go forwards onto their hands, keeping the elbows straight. __ When they can do this well, encourage them to reach out for a toy while keeping the supporting arm straight.

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C9: Encouraging reaching out from lying on a roll

__ Place the child on their stomach lying on a large roll or ball. __ Separate the legs and keep them rolled outwards, that is heels facing in. __ You may want to place the legs on either side of your body. __ Encourage the child to reach out with both hands for a toy. __ When reaching becomes easier, you can hold their things or knees instead.

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C10: Encouraging your child to take weight on the arms (ball activity)

__ Hold the child's thighs, and keep the legs apart and turned outwards, that is heels facing each other. __ Slowly rock the child forwards over the ball until the child's hands are on the floor. __ Encourage the child to take some weight through their hands.

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C11: Encouraging your child to take weight on the arms

__ Support the child's legs on yours. __ Encourage your child to reach forward or 'walk' forward on their hands.

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D: Rolling D1: Rolling over, holding the hips

__ With the child lying on their back, practise rolling from side to side. __ Do this by placing your hand on one hip and slowly moving it so that your child is lying on their side. __ Do this to both sides and do it slowly so that your child has time to move with you. __ When your child is able, you can then carry on to help them to roll right over onto their front.

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D2: Rolling over, using both legs

__ Help your child to roll over from their back to their side. __ Hold the legs as shown. __ Try to dothis slowly so that your child can join in and do as much of this movement as they can for themselves.

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D3: Rolling over, holding one leg

__ With your child lying on their back, hold one leg at the knee. __ Bend the knee slightly and slowly bring it across their body. This will roll your child over onto their side. __ Try to do this slowly so that your child can join in and do as much of this movement as they can for themselves. __ Reverse this to roll to the other side.

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D4: Rolling over, using the arms

__ With your child lying on their back, hold their hands above their head with the elbows straight. __ Slowly bring one arm down and across the body, while keeping the other arm up. __ Encourage your child to look the way they are rolling. __ Use the top arm to guide them, encouraging the top leg to bend to help roll over.

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E: Supine Activities E1: Getting the hands together (1)

__ Support baby behind the shoulders and head. __ This brings the shoulders and arms forwards. __ Encourage baby to look at you and move their arms in front of their body.

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E2: Getting the hands together (2)

__ Encourage your child to bring their hands together, and play with their hands in this position. __ You can also help your child to take their hands to their mouth and reach forward to touch your face.

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E3: Getting the hands together (3)

__ Lay baby on your lap and encourage them to bring their hands together, as shown.

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E4: Encouraging reaching for the feet (1)

__ Encourage your child to touch their feet with their hands by lifting their legs up. __ you can also help by lifting up their bottom to bring their feet closer and/or by putting theirhead and shoulders on a pillow. __ Encourage them to play like this and learnabout their body.

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E: Supine Activities E5: Encouraging reaching for the feet (2)

__ Place your child on your lap, as shown. __ Bring the arms forward and help your child to reach for their opposite foot.

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E6: Bridging (1)

__ Lay the child on their back. __ Bend both knees up and ask the child to lift up their bottom.

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E7: Bridging (2)

__ Lay the child on their back with one leg bent. __ Put the straight leg up on your lap. __ Ask the child to lift up their bottom and hold this position for a few seconds.

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F: Side-Lying Positioning and Activity F1: Laying baby on their side

__ Place a rolled up towel or blanket behind baby's back to keep them on their side. __ When baby is sleeping, a blanket tucked diagonally across from the shoulder will help to keep them lying on their side.

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F2: The side-lying position for play

__ Lay your child on their side to play. __ To stop them rolling over onto their backs, you could lay them against a sofa or large cushion. __ Their head should be in the middle, arms forward and legs slightly bent up. __ You may need to place a pillow in between their legs to keep them apart.

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F3: Using a side-lying board

__ Make sure the child's back is flat against the back of the board. __ A pillow under their head should help to keep the head straight. __ A pillow between the legs will help to keep the legs apart. (Remember to support the feet too.) __ Use the straps to keep the child in this position. __ Encourage your child to bring their own arms forward and play in this position.

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G: Moving From Lying To Sitting G1: Getting up from lying on their front to the sitting position

__ Lay the child on their front. __ Bring the weight backwards over the knees, holding the child's hips. __ Encourage the child to push up with their hands. __ Move the child's hips slowly over to one side so the child is now sitting.

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G2: Getting from lying to sitting: encouraging control of the head (1)

__ Place your hands behind your child's shoulders and gently support the head with your fingertips. __ Make sure that they are looking at you with their head in the middle. __ Bring them slowly up to the sitting position.

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__ Place your hands behind your child's shoulders. __ Make sure that they are looking at you with their head in the middle. __ Bring them slowly up to the sitting position.

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__ From lying down bring your child up to the sitting position, holding their hands. __ Make sure that their head is in the middle and encourage them to grasp your thumbs. Hold them around the wrists. __ Bring your child slowly up to the sitting position, letting them do as much of the work as they can. __ You can help them to go down again in the same way.

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__ From lying down bring your child up to the sitting position by holding one hand. __ Start by tilting them gently over to one side and let them push up with that hand. __ Do This slowly so that your child can do as much of the activity as possible.

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H: Sitting Activities H1: Encouraging head control when sitting

__ Sit your baby on your lap facing you. __ Place your hands behind their shoulders to bring the arms forward. __ Talk and play with your baby in this position, encouraging them to look at you. __ When they are steadier in sitting, you can move your hands to hold the elbows instead.

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H2: Helping your child to sit (1)

__ Sit your child on your lap facing you. __ Hold them around their middle. __ Slowly rock them from side to side, encouraging them to stay upright.

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H3: Helping your child to sit (2)

__ Sit your child on your lap, holding their hands. Let them grasp your thumbs. __ Keep the arms forward and gently bob your child up and down, using your knees. __ You can then try slowly rocking from side to side. __ This all helps to develop balance in sitting, but needs to be done slowly, so that your child can move with you.

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H4: Reaching out while sitting

__ Sit your child on your lap, supporting them at their hips. __ Encourage them to reach out and try to keep their balance.

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H5: Encouraging sitting, holding the shoulders

__ Sit your child on the floor facing you. __ Support them by keeping their shoulders forward. __ Play with toys in front of them.

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H6: Sitting on the floor (1)

__ Let your child sit on the floor to play. Hold the hips to give support and encourage play with toys in front of them __ Later on, when balance has improved, you can encourage your child to reach for toys on either side and keep their balance.

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__ When sitting on the floor to play, hold the child's knees to give support. __ Try to keep the legs rolled outwards, that is with heels facing each other. __ Encourage them to reach for toys to either side and to keep their balance.

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__ Try sitting on the floor with your child supported between your legs. __ One leg can act as an anchor for the child's legs, and the other one as a cushion behind. __ Encourage reaching forward.

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H9: Side sitting

__ Encourage your child to sit as shown. __ Make sure they are taking weight through the arm and that the hand is flat. __ Encourage them to use the other hand to reach for toys and to play.

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H: Sitting Activities H10: Encouraging balance when sitting

__ Sit your child on your lap and hold them at the hips. __ Tilt them slowly to one side and then to the other.

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H11: Sitting astride a roll (1)

__ Sit your child astride the roll, feet flat on the floor and knees bent. __ Encourage them to play with toys in front of them, either on a low table or on the floor.

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__ Support your child at their hips as they bend forward to reach for a toy. __ Encourage them to come back up to the sitting position. __ Use this position also to play with toys on either side of the roll.

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__ Hold your child's legs. __ Gently rock your child from side to side encouraging them to keep their balance.

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H14: Reaching up when sitting on a roll

__ Hold your child's legs to give support. __ Encourage them to reach up and out sideways for a toy. __ This helps to develop balance.

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H15: Reaching sideways when sitting on a roll

__ Sit the child on a roll between two boxes or chairs. Position these slightly forwards of the child. __ Encourage them to reach sideways over to one box for a toy and then to the other. __ Make sure the feet stay flat on the floor.

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H16: Sitting on a therapy ball

__ Sit your child on the ball, holding them at the hips. __ Gently bounce up and down. __ When this becomes easier, slowly tilt them to one side and then to the other. You can try tilting the hips backwards and forwards too. __ Encourage your child to keep their balance and keep as upright as possible.

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H17: Sitting on a stool (1)

__ Sit your child on a stool with their feet flat on the floor. __ Play games involving reaching out in all directions: in front, on the floor, to the sides and behind.

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H18: Sitting on a stool (2)

__ Sit your child on a stool or low table with their feet off the ground. __ Encourage reaching out for a toy while keeping their balance.

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I: Moving From The Sitting Position I1: Moving from sitting to the crawl position

__ Bend one of your child's legs up and turn it slowly to that side. __ Support the child at the hip and under one shoulder. __ Encourage your child to move forward and take weight on their hands and then bring their other knee forward.

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I2: Getting from sitting to standing

__ Sit your child on your lap. __ Bring their weight forward over their feet and help them to stand up.

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I3: Standing up from a low table/chair, holding the shoulders

__ Support your child at the shoulders. __ Bring their body weight forward over their feet and help them to stand up. __ Help them to sit down in the same way.

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I4: Sitting up from a chair, holding the elbows

__ Hold the arms as shown, turned so that the palms face each other. __ Bring the child's weight forward over their feet and then help them to stand up.

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I5: Sitting to standing: sitting down to one side

__ Stand the child up, using their arms to bring their body weight forward. __ Ask the child to sit down to one side and then to stand up again. __ Do the same to the other side.

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Kneeling Activities J1: Encouraging the crawl position (1)

__ Place your child in the crawl position. Support their hips with your legs if necessary. __ Tap gently down through the shoulders to encourage your child to take weight through their arms.

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J: Kneeling Activities J2: Encouraging the crawl position (2)

__ Place your child in the crawl position. __ Support them at the hips. __ Encourage your child to stay in this position for a short while.

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J3: Kneeling up against a surface

__ Support your child at the hips. __ Encourage your child to stay up on their knees, with the weight supported equally by both legs. __ Kneeling against a table is easier to start with. __ Later, using a ball is good for developing balance.

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J4: Playing in the kneeling position

__ Hold your child at the hips. __ Keep their knees apart. __ Play games involving reaching out, such as pushing or throwing a ball.

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J5: Kneeling up on one leg

__ Hold your child at the hips. __ Make sure their legs are apart. __ Play games in this position and encourage your child to keep their balance.

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K: Standing Activities K1: Correct standing posture

__ Head in the middle. __ Shoulders level. __ Hips level. __ Legs straight. __ Weight equally on both legs. __Feet flat.

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K2: Support in standing

__ Stand your child up by supporting them at their hips. __ Encourage them to take as much of their weight as possible and to balance themselves.

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K3: Standing up, holding the elbows

__ Stand your child facing you, holding onto their elbows. __ Keep their arms turned out. __ Keep their feet apart. __Encourage your child to keep their balance.

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K4: Standing against a table

__ Encourage your child to stand up against a table. __ The table should be of a height to allow your child to take weight through their hands.

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K5: Standing between two chairs

__ Stand your child between two chairs. __ Keep their feet apart. __ Encourage them to play by moving toys from one chair to another.

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K6: Standing against a wall

__ Stand your child with their body flat up against knees straight. a wall. __ Their heels should be back against the wall, their knees straight. __ Encourage them to balance in this position.

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K7: Standing against a high table or bench

__ Find a surface that your child can use to help them to remain standing up, as shown. __ Encourage them to keep their balance in this position.

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K8: Stretching up while standing (1)

__ Stand your child on your lap. __ Hold their knees and keep their legs turned out, with feet flat. __ Encourage your child to reach up for toys, so stretching out the body.

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K9: Stretching up while standing (2)

__ Stand your child on your lap. __ Hold one leg straight at the knee. __ Hold the other arm backwards, turned out. __ Encourage your child to reach up for a toy.

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K10: Encouraging standing: holding the knees

__ Stand your child astride a roll. __ Hold the knees, with the child's feet facing forwards. __ Encourage balancing in this position and reaching out for toys.

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K11: Standing, holding the legs

__ Stand your child up against an easel or wall. __ Hold their legs straight and encourage them to tuck their bottom in to stand straight.

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K: Standing Activities K12: Standing with one foot in front of the other

__ Encourage standing in this position.

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K13: Standing with one foot on a step

__ Support your child at the hips. __ Encourage body weight to be forward over the front foot.

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K14: Encouraging standing balance

__ The child's feet should be apart. __ The child should hold on in front and keep their own balance.

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K15: Standing on one leg

__ Shift the child's body weight onto one leg. __ Take the other leg out to the side or behind. __ Encourage the child to keep themselves balanced on one leg.

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K16: Standing with one leg up on your lap

__ Stand the child in front of you, with one leg up on your lap. __ Hold the foot that is on your lap and encourage the child to keep their balance. __ Make sure their bottom is tucked in.

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L: Walking L1: Encouraging walking, holding the hips

__ Support your child at the hips. __ Help your child to move their weight from one foot to the other.

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L2: Encouraging walking, holding the shoulders

__ Support your child at the shoulders. __ Help your child to move their weight from one foot to the other.

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L3: Encouraging walking, holding arms behind

__ Hold the child's wrists to keep the arms straight. __ The arms should be turned so that the palms are towards the floor. __ Help the child to move their weight from one foot to the other.

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L4: Encouraging walking, holding arms up

__ Hold the wrists and hands to support your child. __ Keep the arms turned so that the palms are towards each other. __ Help your child to move their weight from one foot to the other.

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M: Miscellaneous M1: Shoulder movements

__ Hold the shoulder still with one hand. __ Hold the elbow with your other hand. __ Slowly move the whole arm out and to the side and back again. __ The arm can then be brought up towards the ear. __ Turn the arm as you do so, the palm facing towards the ear.

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M2: Stretching for torticollis (1)

__ Support the child on their side. __ Hold the upper leg and the lower arm at the wrist. __ Gently lift the lower part of the body so that the side of the neck is stretched.

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M3:Stretching for torticollis (2)

For the baby with tightness on the left side of the neck (reverse for the other side). __ Lay the baby on their side with their back flat against you. __ Hold the left shoulder steady with your right hand. __ Using your other arm, gently stretch the left side of the baby's neck by moving their head up towards you. __ Hold this stretch position for a few moments. __ Sit the child on your lap facing away from you. __ Hold the left shoulder steady so that the body will not twist when you move their head. __ Gently turn their head to the right.

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M4: Putting on an AFO

__ Hold the child's knee and foot bent up as shown. __ Put the AFO on, making sure the child's heel is right back inside. __ Lastly do the straps up.

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Alphabetical List of Illustrations B Bridging (1) 51 Bridging (2) 52 C Carrying baby curled up 23 Carrying baby facing away from you 26 Carrying baby on your hips 24 Carrying in the 'aeroplane' position 25 Carrying your child to help strengthen the back 27 Correct standing posture 89 E Encouraging balance when sitting 70 Encouraging head control when sitting 61 Encouraging reaching for the feet (1) 49 Encouraging reaching for the feet (2) 50 Encouraging reaching out from lying on a roll 39 Encouraging sitting, holding the shoulders 65 Encouraging standing balance 102 Encouraging standing: holding the knees 98 Encouraging the crawl position (1) 84 Encouraging the crawl position (2) 85 Encouraging walking, holding arms behind 107 Encouraging walking, holding arms up 108 Encouraging walking, holding the hips 105 Encouraging walking, holding the shoulders 106 Encouraging your child to take weight on the arms 41

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Encouraging your child to take weight on the arms (ball activity) 40 G Getting from lying to sitting:Encouraging control of the head (1) 57 Getting from lying to sitting:Encouraging control of the head (2) 58 Getting from lying to sitting:encouraging control of the head (3) 59 Getting from lying to sitting: encouraging control of the head (4) 60 Getting from sitting to standing 80 Getting the hands together (1) 46 Getting the hands together (2) 47 Getting the hands together (3) 48 Getting up from lying on their front to the sitting position 56 H Helping to separate the legs 21 Helping your child to sit (1) 62 Helping your child to sit (2) 63 K Kneeling up against a surface 86 Kneeling up on one leg 88 L Laying baby on their side 53 Laying baby prone on you 34 Laying the older child on their front 37 Lifting your child up from the floor (1) 28 Lifting your child up from the floor (2) 29 Lifting your child up from the floor (3) 30 Lying on their front to play (1) 31 Lying on their front to play (2) 32 Lying on their front to play (3) 33 Lying on their front to play (straight arms) 36

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M Moving from sitting to the crawl position 79

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O Opening hands and fingers 18 Over a roll with weight on the arms 38 P Play over legs 35 Playing in the kneeling position 87 Putting on an AFO 112 R Reaching out while sitting 64 Reaching sideways when sitting on a roll 75 Reaching up when sitting on a roll 74 Relaxing a tight arm 19 Relaxing baby 11 Relaxing baby on your lap 10 Relaxing over a ball (holding arms) 15 Relaxing over a ball (holding legs) 14 Relaxing the body 12 Relaxing the body by moving the legs 13 Relaxing the toes 22 Relaxing your child in the sitting position 16 Rolling over, holding one leg 44 Rolling over, holding the hips 42 Rolling over, using both legs 43 Rolling over, using the arms 45 S Shoulder movements 109 Side sitting 69 Sitting astride a roll (1) 71

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Sitting astride a roll (2) 72 Sitting astride a roll (3) 73 Sitting on a stool (1) 77 Sitting on a stool (2) 78 Sitting on a therapy ball 76 Sitting on the floor (1) 66 Sitting on the floor (2) 67 Sitting on the floor (3) 68 Sitting to standing: sitting down to one side 83 Sitting up from a chair, holding the elbows 82 Standing against a high table or bench 95 Standing against a table 92 Standing against a wall 94 Standing between two chairs 93 Standing on one leg 103 Standing up from a low table/chair, holding the shoulders 81 Standing up, holding the elbows 91 Standing with one foot in front of the other 100 Standing with one foot on a step 101 Standing with one leg up on your lap 104 Standing, holding the legs 99 Stretching a tight arm 20 Stretching arms forward 17 Stretching for torticollis (1) 110 Stretching for torticollis (2) 111 Stretching up while standing (1) 96 Stretching up while standing (2) 97 Support in standing 90 T The side-lying position for play 54

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U Using a side-lying board 55

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SECTION 3 OTHER INFORMATION ON DEVELOPMENT

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Your Child and Play Playing and Learning Go Hand in Hand Children seem to have a natural instinct for play and, through play, they learn about the world around them. Children use play to express their feelings and to communicate with other people, even when they are quite young. They do not always need expensive toys to play with. The trick is to try to find games and toys which interest your child and match their abilities. Toys that are too difficult will be frustrating; toys that are too easy will become boring over time and be abandoned. Children who have physical problems often need help to play with toys and games. These children may be slower to understand how toys work or less able to make them work. Your child may lack the strength or energy or simply not have much curiosity to experiment with a new toy. This is especially true for children who have difficulties with their movement. How You Can Help __ Bring toys within your child's easy reach. __ Make sure that toys are not too heavy to hold or lift. __ Choose toys which are exciting, but not too frightening. A loud sound may take some time to get used to. __ Show your child how a new toy works and guide their hands. __ Show them how pleased you are when they have been successful.

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__ If your child is not interested or gets irritable when you help them to play, do not become disheartened. Try to think of any reasons for the play activity not being right for your child. Toys and games are not a substitute for contact with other people. Make sure that your child's play draws in other people, especially other children. Quite often disabled children are left out. Help them to notice others and to be noticed. Help them to share, and encourage other family members to include them in their activities. How Play Develops At first children enjoy toys which are interesting to look at: brightly coloured, for example, or with parts that move. Later they become more interested in toys which they can move with their hands, especially if they produce a result such as a noise or music, pop-up toys and toys such as puzzles which make them think. Do not forget to encourage children to touch and explore objects, to expand their experience. Toys are useful for children who need help with movement. They can be a good incentive for children to move their bodies, as when reaching for a toy or moving towards a toy. Toys and games often act as comforters. Soft toys also give the chance to play make-believe. This is very important for all children's thinking and understanding. Make sure that your child has a teddy or doll around once they are able to hold on to larger toys. You and your child can begin to include teddy in games such as 'pretend' tea parties and even include him in your child's exercises.

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Do make sure that you use everyday experiences as much as you can to help your child play and learn. Let them crawl into boxes or under tables to play as often as you would any child. Let them drop and scatter toys, but do encourage them to pick them up once they are strong enough. Be as keen and interested in small steps to progress as in those big experiences with special toys. Finally, build in play times as part of the everyday routine. Talk and explain to your child while you play. Keep going, keep to what is manageable for you and your child, and make it fun for both of you. Your physiotherapist and speech and language therapist will be able to give more practical advice about the sorts of activities that will help your child best at each stage of development. They can also advise on the sorts of toys that will suit your child's needs and interests.

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Everyone Needs to Communicate One of the most important skills your child will learn is to communicate effectively. Communication begins long before your child is speaking. As parents, we communicate with our babies by looking, touching and changing our tone of voice. Babies tell us a lot about how they feel through movement and facial expression and, of course, by crying and making sounds. It may be a long time later that they start trying to talk, but this early stage of unspoken communication is essential to the development of understanding and relationship. A child's early experience and relationships with others will strongly affect whether or not they want to communicate. Their ability to make sense of the world will affect the ideas they are able to understand and communicate about. Some children have a good understanding but have physical conditions which make mouth movements difficult. These children have just the same need to express themselves as others and it is important to prevent frustrations by offering them additional ways of communicating as soon as possible. The type of help a child may need to develop good communication skills may change as they grow. A speech and language therapist should be able to offer advice and decide with you what is appropriate for your child. Many children simply need a little extra help to develop skills and achieve their potential. Some may benefit from simple signing, others may learn to indicate their needs using pictures and a few will require mechanical aids or computers. Whatever difficulties you child may be experiencing at the moment, it is important to remember that you, your family and friends are the best people to give the help they need.

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Getting Started From the start, it is important to watch and listen to your child. Your child is also learning to watch and listen to you. Children listen to the sound of your voice long before they understand what you are saying. Playing with sounds while you are handling your child can be very reassuring. Babies soon learn to enjoy this early play and especially like their own sounds being repeated back to them; in this way they know they are being listened to. Soon they begin to expect these games and may indicate that they want more by becoming noisier or waiting expectantly at times when these games are normally played. Songs and rhymes combine sound and movement and can be exciting or soothing to a child who is depending on you. They also help children learn about the patterns of speech. Some parents recognise at this stage that their child is not responding because they have problems hearing or seeing. It is important that early help is available as hearing and visual impairments will affect the child's development and interfere with speech and language learning. What is Your Child Trying to Tell You? However your child communicates, with spoken words, gestures or by other means, they rely on you to understand them in order to feel successful and keen to keep trying. A child who does not have an effective means of communication and is usually misunderstood or ignored may become depressed or angry. Such children can become dependent on one person to meet all their needs or may develop difficult behaviours.

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Show an interest in the things your child enjoys and always talk about what they are doing. Keep your language simple and to the point. Use your hands and facial expressions to emphasise what you are saying. Once your child begins to attempt to say or indicate words, give them lots of encouragement. Saying ''yes", smiling and repeating the word back may be all that is required. It is not helpful to correct your child's efforts all the time, however much you want them to progress. Once your child is using words regularly to draw things to your attention, you can begin to extend what has been said. For example, you could respond to, "Mummy bus" by saying, "Yes. It's a big bus." Things to Remember __ Listen to your child and watch what they are telling you. __ Let your child know they are understood __ Give your child opportunities to listen and develop their attention: for example, playing with sounds; singing songs with actions; looking at pictures together; telling stories. __ Use your face and hands to express yourself as you talk to your child. __ Repeat your child's speech back to them and gradually add to their ideas __ Make your child aware of your pleasure in their attempts to do and say things, even if they are not always correct. __ Help your child to feel successful, however they communicate.

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