1. Our inner core muscles turn on first. 

The inner core muscles consist of the respiratory diaphragm, the pelvic floor, the transversus abdominis and the multifidus.  The inner core muscles activate as a team in the same manner before every movement that we do.  They function to give us a stable spine and pelvis before movement begins.  The respiratory diaphragm receives input from the vestibular system (hurray, another link between sensory and motor functions!) During the process of neurological and motor 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 both neurological and alignment issues.

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

Unlike the inner core muscles, which come on in the same manner regardless of the movement, the timing of recruitment of outer core muscles depends on the task. The inner core muscles create an anchor at the center so the outer core muscles have something to stabilize on and can function 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 and extremity muscles instead and this causes their clumsy 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 move quickly through this as their alignment improves.  Alignment supports core strategy.  Children with motor challenges continue to use breath holding as their way of creating a stable center.

And now how do we apply this new knowledge 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 in every activity builds core strategy, which is critical for endurance and strength.  

2.  A is for alignment.

Our children need to experience what it feels like to have a neutral rib cage in relationship to a neutral pelvis.  Many of our children tuck their bottoms under (posterior pelvic tilt) or pop their bellies out (anterior pelvic tilt).  Then they shift their rib cage forward or backward in an effort to keep the body balanced.  A different alignment is needed to be able to activate the inner core muscles.

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. We also need to retrain the respiratory diaphragm by encouraging expansion of the lower rib cage so that they can take a full breath.  In this way, the diaphragm is fully engaged and the inner core team becomes active.

4.  Movement should be fun.

Ultimately we want our kids to take their core with them wherever they go!  They use 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.

When we work with children an up to date understanding of core muscles and how they work is crucial.  Activation of the inner core should be our priority as this team of muscles supports our children in every single function they do.  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.

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 THE VISUAL SYSTEM
We’ve just talked about vestibular input but visual input also 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.
To learn more about core strategy and Dynamic Core for Kids check out my blog http://heartspacept.com/blog/dynamic-core-for-kids/ and Dynamic Core for Kids courses  at http://heartspacept.com/workshops/  .  Also check out  www.juliewiebept.com  for more information on core strategy in adults.

5. PRACTICE PROBLEM SOLVING
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.

2. The vestibular system rocks! The vestibular system is found in the inner ear and it is the most important sense for movement. It has far reaching inputs in the brain including: position in space, orientation against gravity, balance, how fast we are going and which direction we are going. This system also influences vision, contributes to postural tone and assists in regulating our emotions. Specific movements through space can activate the different parts of the vestibular system.

3. The Core is crucial.The 4 inner/anticipatory core muscles (respiratory diaphragm, pelvic floor, transversus abdominis, multifidus) provide central stability which is essential for balance as well as our perceptual sense of midline. If our core is weak/inefficient, then our balance will be decreased. If our sense of midline is compromised, our ability to complete activities that use that midline as a reference will be difficult ex. catching a ball, buttoning our coat or reading print on a page. Alignment is the key to activation of both the anticipatory and reactive core muscles.

4. Fear is the enemy.For most of us, it is easy to match our emotional state to the demands of the task. For example we need a different level of arousal when we are standing in line at the bank than when we are standing waiting for a pass in basketball. And we can also change our state easily as we change tasks – we call this emotional self-regulation. But some children have difficulty with this because their nervous system is in a state of permanent stress. We can’t learn effectively when the brain is functioning in this survival mode because attention is focused on the “threat” not on the details of movement. We need to help set both the internal and external environment to a child’s “just right state” for movement learning.

5. Learning motor skills requires practice and problem solving.Initially to learn a new motor skill it is best for us to practice a many times in a row. Then we practice it randomly. Finally we can practice our new skill in different environments and develop alternate ways to accomplish the same goal through problem solving. Here’s an example of how this process might look with a child: Sally wants to learn to hop on one foot to play with her friends at recess.

Practice a new motor skill many times in a row: Sally learns to stand on one foot and hop. She practices in the therapy gym many times in a row.

Practice the skill randomly. Sally begins to practice her hopping in between different activities during therapy.

Practice in different environments. Sally begins to practice hopping at home in her room, in the kitchen and in the driveway.

Develop alternate ways to accomplish the goal through problem solving. Sally finds it more difficult to hop when she is in the driveway and indicates it is because there is more noise. Sally decides she can count out loud to help her develop a rhythm and focus on hopping rather than the noise.

When we look at movement it is best to look at all the systems and how they work together for each person. The brain works best with input on many different levels so we can create flexible options developed through preparation, guidance and experience.

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 for the same reason.

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 with Julie Wiebe, PT. For more information please refer to previous blogs on HeartSpace Physical Therapy for Children or go to Julie’s website at http://www.interiorfitness.com/ Photographs used with permission.

We have discussed before that the adult physiotherapy literature has clearly defined the inner Core as the respiratory diaphragm, transversus abdominis (TA), pelvic floor (PF) and multifidus. These four muscles have unique properties that integrate their function as the centre piece of anticipatory postural control. This subject has been researched extensively in the adult literature, but has just begun to be addressed in paediatric research.

MD: 12 year old boy with spastic right hemiplegia CP, born at 25 weeks, weighing 971 grams.

Presentation:

• Range and strength issues in right UE, LE and trunk
• Compensatory range and strength issues in left trunk and leg
• Difficulties with visual scanning, attention
• Poor sitting posture (stabilized in posterior pelvic tilt, thoracic flexion and forward head posture, eye gaze elevated, right hip fell into external rotation and slight abduction (see photo Sept 09 )
• Poor standing posture (anterior pelvic tilt, asymmetrical weight bearing through LEs L > R, lumbar extension, thoracic flexion and forward head posture, eye gaze elevated, right posterior trunk rotation, right pelvic retraction (see photo Sept 09)
• Functional limitations include sit to stand requiring UE support, poor sitting tolerance (10 minutes or less before requiring movement), poor standing balance (increased postural sway and increased frequency of falls)
• Observational gait analysis: decreased right stance phase, right single limb support stabilized through right lateral trunk flexion, right posterior trunk rotation and right pelvic retraction at midstance, reduced right push off at terminal stance

Core deficits:

• Breath holding for transitional movement and to prepare for challenging motor tasks indicating poor diaphragm function
• Inability to hold midrange postures in any position, stabilizing in either end range posterior tilt (sitting) or anterior tilt (standing) indicating deficit in all four Core elements
• Pelvic retraction and poor midrange hip control during midstance phase in gait indicating poor pelvic floor engagement to stabilize the pelvis and anchor the hip
• Poor anticipatory postural control in sitting, standing and gait, indicating poor timing of Core recruitment

Intervention:

The physiological relationship between the four components of the inner Core unit led us to develop an intervention approach that utilizes diaphragm as the gateway to anticipatory engagement of all four Core components (“Dynamic Core for Kids”). The optimum position for diaphragm recruitment and subsequently the other components of the Core is neutral pelvis and rib cage.

We initially accomplished this for MD by teaching proper diaphragm engagement before he began transitional movements; the phrase “blow before you go” was an important verbal cue. Critical to his ability to fully utilize his diaphragm was to create neutral ribcage and pelvis position through the use of pillows in supine and wedges in sitting. As anticipatory Core engagement improved, treatment progressed from the inside-out. This is defined as activities that paired anticipatory Core engagement with postural synergists, the muscles that accomplish postural stability, rotation and functional movement. This resulted in MD achieving and maintaining more neutral postures, stabilized by the Core, independent of external support. A postural seating support (wedge) continued to be utilized to maintain proper alignment and build endurance during home and school activities that required prolonged positioning.

Treatment was provided over a series of weekly 1 hour sessions for 2 months to address sitting posture.

September 2009
November 2009
November 2009	Treatment was subsequently provided for another series of weekly 1 hour sessions for 2 months to address standing posture.
September 2009
March 2010

Results:

As seen in the series of seated photos, MD made a significant improvement in maintaining a more neutral alignment both with and without seating support. Functionally, MD now sits independently for school work without time limitations secondary to physical endurance. The alignment improvement also brought a significant change in his eye gaze positioning, which has the potential to impact both social interaction and school work success. His seated alignment also positions him for a more optimal transition from sit to stand and he now moves from sitting to standing without using his UEs. Similar improvements are evident in the standing photos, with significant reduction in postural sway and improved immediate standing balance after rising from sitting. There were anecdotal reports by parents that MD displayed improved standing balance.

Conclusion:

This case illustrates the possibilities for improved postural control and motor function in a child with CP using the Dynamic Core for Kids approach.

The Physical Therapy research literature over the past decade has targeted the inner core unit and how it functions.The inner Core unit is made up of the respiratory diaphragm, the pelvic floor, the Transversus Abdominis and the Mulitifidus.It turns out that these 4 muscles turn on prior to movement, and they work together as a team, regardless of the direction of the movement.In other works, they anticipate and provide central stability prior to any movement.Other outer core muscles turn on in different patterns, dependent on the direction and magnitude of the movement.We can refer to the inner Core muscles as the anticipatory core and the outer core muscles as the reactive core (for more information please go to www.interiorfitness.com and read Julie’s blog, “Core Conversations: The Anticipatory vs. Reactive Core”).All provide a stable center but in a different manner.The activation of the team of inner Core muscles is alignment dependent; that is to say, if our alignment isn’t optimal, neither is the activation of our inner Core muscles and therefore we don’t have a stable center before we move.

In typical development, Core activation in postural control happens smoothly.At birth, physiological flexion provides our central stability.The central nervous system is maturing over the first several years and as this happens there are more connections and more consistent connections formed between muscles and nerves (corticospinal and vestibulospinal tracts are primarily responsible for postural tone).This causes the resting tone in our inner Core muscles to increase during our first 2 – 3 years.Further, our desire to explore the world through vision and touch drives our movement exploration.Each time a baby turns their head to use their eyes, or reaches out for Mom, the inner Core muscles have prepared a stable trunk.The more we move and explore in different positions, the more sensory information we process.This allows us to control our alignment against gravity and our anticipatory Core function becomes more consistent.Eventually there are instantaneous connections between the sensory systems, the anticipatory Core and all the other muscles of the body.The musculoskeletal, sensory and motor control systems work together for smooth, coordinated functional movement.

In our children with movement challenge this scenario goes awry.Children who are born prematurely don’t have adequate physiological flexion to provide central stability.Children with low tone don’t develop adequate resting muscle tone in their Core musculature and don’t have the strength or endurance to maintain alignment.Children with spasticity can’t spontaneously access an appropriate alignment that allows efficient activation of the Core muscles.Children with sensory processing difficulty don’t register and/or process appropriate levels of vestibular sensory input, which impacts directly on resting muscle tone, the level of activity in the respiratory diaphragm (a key Core muscle) and their perception of alignment.Children can also experience difficulty with activation of their Core muscles secondary to non-neurological issues.For instance, abdominal surgery impacts directly on several muscles of the inner Core unit and can interfere with its function. When our children have difficulty with function of the inner Core unit, they create compensations in their body that supports their central stability and therefore their functional movement.Primarily they hold their breath as a way of creating central stability in order to complete the task.Other compensations include holding their arms tight to their sides, using trunk asymmetry or locking a joint at end range.Each child creates his/her own unique set of compensations which provides a degree of central stability in that moment but these usually interfere with the development/refinement of further functional skills.

Dynamic Core for Kids accesses the inner Core unit by addressing alignment and breathing.Not only do we need to be attentive to alignment of the pelvis and spine but the alignment of the rib cage is also critical.Once alignment is present, children need to be taught to breathe in all planes rather than just relying on upper chest and/or belly breathing patterns.Finally, this new Core strategy needs to be connected to the outer core muscles so postural control supports functional movement efficiently.

In my next post, we’ll look at how this process worked for a 12 year old child with Cerebral Palsy.

There are 3 senses that are hugely important to postural control/balance – proprioception, vestibular and vision.

Vision: our visual sense not only registers the characteristics of the object but also where it is in space in relation to our body.

Proprioception: the sense of where our body is in space, as registered by our joint and muscle receptors.

Vestibular: the sense of where our body is in space, specifically in relation to gravity as registered by the vestibular mechanism in the inner ear.

Vestibulo-ocular reflex: the connection between the visual and vestibular systems that keeps the image in the centre of our visual field as we move our heads.

We know that as children we use vision as our primary sense for balance until we are 6 years old. After that we begin to be able to combine the visual input with our proprioceptive and vestibular input between the years of 6 to 12 years. Finally, after 12 years of age we begin to be able to successfully solve balance tasks that involve sensory conflict. Consider the classic example of sensory conflict: you are sitting in a train, looking out the window and the train right next to you begins to move. It takes you a moment to figure out that the other train is moving but you are not; this is sensory conflict. This progression in the sophisticated use of sensory information is secondary to the maturation of the vestibulospinal tract and the consequent maturation of the vestibulo—ocular reflex.

It is not surprising that many children who experience challenges with movement retain their reliance on their vision for postural control. Children who experience difficulties with their registration and processing of proprioceptive and vestibular information, have difficulty knowing where they are in space. They consequently cannot move beyond vision to more complex sensory processing for balance. In addition, the vestibular system is critical in setting the amount of anti-gravity muscle tone and it modulates the amount of activity at the respiratory diaphragm (via the vestibulospinal tract). The diaphragm happens to be one of the 4 key inner Core muscles responsible for anticipatory postural control. When the vestibular system is not functioning properly, our postural control is compromised in this way as well. Unfortunately all of this makes the coordination for higher level balance skills and higher level gross motor skills a challenge.

Also, some of our children are sensitive to visual input. Over 50% of the brain is devoted to processing visual information on some level, and a lot of visual information can be overwhelming for these children. They may avoid paying attention to information regarding their position in space in order to avoid visual overload.

Finally, many of our children do not have a solid connection between their visual and vestibular systems. The vestibulo-ocular reflex enables the eyes to stay centred and steady as our head moves. This reflex functions even when we are “at rest”, as we have a natural postural sway in quiet sitting and standing. When your eyes don’t keep up with the movement of your head, you process information about where you are in space (and the objects in that space) much slower, and incoordination can result.

All in all, the sensory systems make an enormous contribution to postural control and the development of motor skills. It’s best for us to remember that every motor event begins as a sensory event and pay equal amounts of attention to the sensory systems, the musculoskeletal system and the motor control system.

Kim Barthel, OT, will be teaching Seeing, Moving May 4 – 6, 2011 in St. Catharines. This course will increase our understanding of the neurobiology of the visual and vestibular systems and discuss the brain mechanisms that support the integration of these systems through functional treatment strategies. For information, email shelley@heartspacept.com