I’m going to come right out and say it.
I’m a pediatric physical therapist, and I think W-sitting is OK.
Like most physical therapists, I learned in school that W-sitting is bad. Very bad. The worst. When I talk to other physical therapists, even those who don’t treat children, they remember the same thing. In a recent conversation, one colleague recalled the time she came home from PT school in a panic because her then-5-year-old sister was a W-sitter. It is a single, pervasive, clear message taught to physical therapy students everywhere. W-sitting must always be corrected. But why?
The reasons given usually fall into 3 categories:
- W-sitting will cause orthopedic issues such as twisted bones and hip dislocation.
- W-sitting will cause muscle tightness, especially in the hips.
- W-sitting will aggravate neurological issues such as low muscle tone.
For the first several years of my practice as a PT, I taught families about the dangers of W-sitting, reciting the 3 reasons over and over again. For the first couple of years I taught pediatric PT, I passed these beliefs onto my students.
Then I became a mother. And my son was a W-sitter.
And for the first year or so of his life, as he played, I chirped “Fix your feet!” and moved him, over and over again, into other sitting positions. At first, it wasn’t a big deal. But then he started to get frustrated with me. And I started to get frustrated with him. And I noticed that, when I moved him to a new position (or forced him to do so himself), he often wasn’t able to play as well or effectively as he was before my “intervention.” He was a happy, bright, social kid. He was developing normally, hitting all his milestones on time, and had no orthopedic or muscular problems that I could identify. So I stopped worrying about it. I stopped correcting him. I started to wonder why I had been correcting W-sitting just for the sake of correcting W-sitting. And I started to think really carefully about what I was really doing when teaching families to discourage W-sitting.
The truth is, as common as it is for therapists to teach children to “fix your feet,” there is really no evidence to support this practice. A quick Google search for “W-sitting” reveals hundreds of posts about W-sitting, most written by physical and occupational therapists. Almost without exception, they caution against W-sitting. Almost without exception, they give the 3 reasons that W-sitting is bad. But, in reviewing all 10 posts on the first page of search results on W-sitting, not a single one provides any references for those claims. Searches for W-sitting on Google Scholar and PubMed come up empty.
“Fix your feet!” For a practice with such a high level of adoption, there sure is a low level of evidence.
Now, I don’t dispute the fact that children with low muscle tone often choose W-sitting as a preferred position. It gives them a wide base of support which makes them really stable. But you know what that means? They are functional in that position! They can use their hands better and manipulate toys better because they aren’t using all their energy just trying not to fall down.
I also understand that often, children who W-sit often have orthopedic issues and muscle tightness. But I don’t think that we can confidently say that W-sitting CAUSES those issues. Perhaps it’s the other way around – unstable hips and tight hamstrings lead to W-sitting. Or maybe there’s a third variable that’s causing both problems. The truth is we don’t know.
And many might argue, “What’s the harm? It won’t hurt to take them out of W-sitting. Why wouldn’t we correct it?” My response would be that correcting it might actually be harmful. Perhaps not for the child’s physical development. But what about their interactions with their parents? Is constantly having a parent telling their child to “fix their feet” promoting good parent-child interactions? What about parents who worry constantly about their child’s W-sitting? How much stress and worry are we therapists causing over something we really can’t even prove causes harm? And finally, what about function? What are we taking away from the child when we correct W-sitting?
So perhaps we therapists should soften a bit on W-sitting. Not that we should NEVER correct it – sometimes it is clearly problematic for a child. But we should recognize that W-sitting isn’t an all or nothing proposition. It can be normal and is not always be dangerous or bad. It doesn’t always need to be corrected. Let’s look at children as individuals, address their real impairments, and always keep our eye on enhancing participation rather than reinforcing “normal.” If low tone and core strength are the issues, let’s address those. Let’s provide opportunities for a variety of movements and help children explore different sitting positions.
Kids are smart. They usually know what they need. And the body has a way of finding the most effective and efficient way to move. For many kids, W-sitting isn’t a problem, it’s their solution.
As my youngest son is just starting to stand on his own, cruise along the coffee table, and walk with a push toy on his own, I have been reminded once again how amazing and significant learning to walk really is.
As a physical therapist, one of the most common questions parents ask me is, “When will my child walk?” Walking is a developmental milestone that is extremely meaningful for children and families. For children, walking leads to independence, exploration and learning, as well as improved ability to socialize and participate in home and community life. For families, walking is a very visible sign that their child is developing and healthy, and relieves the physical burden of having to carry or wheel their child everywhere.
Although there are many different “normal” variations of learning to walk, walking is a very visible skill and it is hard for parents NOT to compare their child to others they see. It is even harder to avoid listening to well-meaning friends, family, and even strangers ask questions and offer advice about walking, particularly if your child is a late walker (Is he walking yet? No? Well you just need to get him some hard-soled shoes!). I’m here to set the record straight with a few fun facts about walking.
1. 90% of healthy, typically developing children will take their first steps sometime between 9 and 15 months of age. On average, a child will take his first steps right before his first birthday, but this can vary widely from child to child. This does not mean that something is wrong if you child doesn’t walk by 15 months. I have seen many typically-developing children walk at 15-18 months or later, and late walking is rarely a sign that anything is wrong. However, in rare cases, late walking can be associated with neurological or genetic conditions, so it is a good idea to talk to your pediatrician if your baby isn’t walking by 15-18 months of age.
2. Learning to walk involves multiple body systems. In order to take his first steps, a child must have sufficient strength to hold his body up and the ability to move his legs in a walking pattern. The brain must be able to send signals to the body to activate the correct muscles in the correct order, the sensory systems must send information back to the brain about how the environment looks and feels, and the child must be motivated to walk. Even body shape/size plays a role – infants have a very large head relative to the body and one of the most challenging aspects of walking is overcoming that top-heaviness and controlling the head over the body. Children who are smaller or shorter may walk earlier than children who are larger or taller or have relatively large heads. The bottom line is this – no matter how “strong” or “smart” or “determined” your child is, he won’t take his first steps until all of his body systems are ready.
3. The best way to help a child learn to walk is: TUMMY TIME! It may seem counter-intuitive, but the best way to teach your baby to walk is to lay him on the floor on his tummy and let him learn to play, move, and explore. When babies are born, they have been packaged in the womb for 9 months and their bodies are sort of stuck in a flexed or fetal position. They have little to no ability to hold up their head, neck, and trunk. In the first few months, tummy time is critical to help babies stretch out the muscles on the front of their bodies and strengthen the neck and upper back. By the middle of the first year, babies begin to push up on their arms and come to hands and knees, strengthening their lower back, pelvis, hips and legs. All of these things are critical for learning to pull to stand, step, and walk.
4. Barefoot and soft-soled shoes are best for new and emerging walkers. See my previous post for more information on this.
5. Baby walkers are bad for development of walking. Apart from serious safety concerns (the American Academy of Pediatrics has called for a ban on baby walkers in the US and they have been banned in Canada for many years), baby walkers don’t help babies learn to walk. In fact, research shows that children who spend time in baby walkers actually tend to walk later than their peers who do not. Baby walkers put babies in an unnatural standing position, take away the ability to see the legs and feet during stepping, and deny opportunities for crawling and pulling up. For parents who need to keep their baby contained for a few minutes, a playard or a gated baby-proofed room are much better solutions. And for learning to take first steps, a push toy allows baby to see his legs and feet and practice standing and stepping in a much more natural way. There are commercial push toys available, but most families have ordinary objects around the house that will work just fine – a play grocery cart or doll stroller, empty laundry basket, or large box are all perfect for holding on and pushing around the house.
6. Walking posture changes significantly in the first 3-4 years. Flat feet, walking on toes, or walking “bow-legged,” “knock-kneed,” or “pigeon-toed” can all be normal in the first few years of life. Walking typically looks adult-like by age 6-7. If you’re concerned about your child’s leg or foot posture during walking, you should talk to your pediatrician or physical therapist to find out if your child needs to see an orthopedic specialist or is a candidate for foot orthotics. But, as long as what you are seeing looks the same on both sides and isn’t causing any pain or problems with function, there is a good chance that what you are seeing is one of the many variations of “normal.”
The developing brain and body are truly remarkable, and the journey to walking is different for every child. My own sons are a perfect example of this. My oldest didn’t take a step until he was over 13 months old and didn’t walk well until he was nearly 15 months. It took him several more months to be comfortable walking on uneven terrain such as grass and gravel. My middle son took his first steps at 11 months and never looked back. By his first birthday, he was practically running everywhere – in the house, across the yard, and at the park. My youngest is now 9 months old and is already beginning to stand on his own. I suspect he’ll take his first steps within the next few weeks. All three of my boys developed their walking skills completely differently and on their own timetables. But you know what? They’re all absolutely typical and equally awesome!
Walk on, my little friends!
The APTA House of Delegates kicked off its 2013 session tonight in Salt Lake City, Utah. Tonight’s House activities consisted primarily of introductory remarks, elections, and some logistical/procedural items to get us ready to dig into House business first thing tomorrow morning. Here’s a quick recap and a few things you need to know:
All 2013 motions with their original language are published in Packet I on the House Community and on the APTA HOD 2013 website. If you’re interested in the business of the House, Packet I is a good place to start. However, there’s a LOT of collaboration and discussion that goes on before and during the House as Delegates work together to edit motions, compromise, and come to a consensus on language. This collaboration is a good thing, and the fact that it happens OFF the House floor is important and necessary. However, it makes it challenging at times to stay up-to-date on the most current motion language. Packet II has already been posted with updated language on the following motions: RC 2, RC 7, RC 8, RC 16, RC 22, RC 27, and RC 29. More changes are coming, and Packet III with more updates will undoubtedly be available soon. Updated packets can be found in the “Onsite Packets” section of the HOD Community.
The main event today was Board of Directors & Nominating Committee elections (click here to learn more about the 2013 Slate of Candidates). I’m embarrassed to say that – before I became a Delegate – I had no idea how APTA officers were elected. So here’s the drill. Prior to the HOD, candidates prepare a number of materials that are posted online. Once at the HOD, they participate in candidate interviews, where they spend a morning rotating through rooms full of Delegates, answering questions from different Chapters and Sections. After a brief lunch break, the candidates participate in a “meet and greet” session where they have an opportunity to meet Delegates in a more informal, personal environment. A few hours later, the first order of business of the HOD is to hold elections. Here are tonight’s election results:
Secretary – Laurita Hack
Vice Speaker – Stuart Platt
Director (3) – Roger Herr, Susan Whitney, Carolyn Oddo
Nominating Committee (2) – Cecilia Graham, Peggy Newman
Did I mention that these people VOLUNTEER their time and – if elected – spend more than 40 days per year away from their friends and families? Major kudos to all candidates and congratulations to the winners!
The HOD will be back in session at 8:30 tomorrow morning (local time). Want to follow along? Check out the APTA HOD livestream, follow @APTAtweets and the #APTAHOD hash tag on Twitter (you can also follow me @KendraPedPT), and check the APTA HOD 2013 website and/or House Community for updates.
Introduction to 2013 Motions by Speaker of the House Shawne E. Soper (from http://www.apta.org/HOD/2013/)
In one month, the APTA House of Delegates will convene for its 2013 session.
During last year’s session (my first), social media played a role for the very first time. The House discussed and ultimately adopted what began as RC 23-12 and is now the Standards of Conduct in the Use of Social Media. Going into my first House session, I naively thought that it wouldn’t be a big deal if I used social media. Honestly, I didn’t think anyone would really notice. I was wrong. Many House members had concerns when I (and others) participated in social media discussion before and during the house. Live-tweeting candidate interviews was particularly objectionable, I learned. Social media was new to the House, and questions were understandable. We all learned from the process. I’ve already written about all this, so I won’t was time rewriting it all here (but I encourage you to read this and especially this to get up to speed on social media during the 2012 HOD).
All of this is to say…
We’ve come a long way in one year.
This year, for the very first time, all motions that will be brought forward in the House of Delegates are available for viewing and comment by members, non-members, and the public via the 2013 House of Delegates Web Page. The page has a link to language for each motion, including information on which Chapter/Section brought the motion forward. And, for those of you who are on Twitter, @APTAtweets has established a hashtag for each motion, so you can tweet about or follow online conversations on motions that particularly interest you. I am loving this page versus the members-only House Community Group, which I find extremely clunky, unintuitive, and difficult to follow. But that’s just my opinion, and that’s the point – these new initiatives open up MULTIPLE, interactive channels for communication so that everyone can engage in the process, whatever their membership status or online/social media preferences.
So here’s the deal:
There are no more excuses for being uninformed or for not engaging in the process.
Every single physical therapist should go to the online House Community or the 2013 HOD Web Page. Read through the RC’s. Take note of who brought the RC forward (or those who are co-sponsoring) and if you have questions, contact those people. If you want to discuss a motion or have questions or comments, contact your Delegate – it is usually easy to get contact information for your Chapter’s delegate by contacting your Chapter or visiting your Chapter’s web site.
If you’re not that into social media or have something to say that can’t be said in 140 characters or less, leave a comment on the House Web Page. If you’re a Twitter user, start a conversation on Twitter using the hashtag for the motion (and, ideally, #APTAHOD as well).
I’m a Twitter user, and I am frequently struck by the passion of the physical therapists and students who engage in Twitter discussions about our profession. But I still see a disconnect between the intensity of the online discussions (which always include lots of ideas about what the APTA and the profession should be doing) and the lack of participation in the House of Delegates (where one can actually shape what the APTA and profession is doing). The House of Delegates is where policies are made, our organization’s leaders are elected, our profession is defined, and decisions are made about how to move forward. For members. By members. Whether you want to post or tweet, have lunch with your Delegate to talk about a motion, reach out to an APTA leader (incidentally, Nicole Stout is now a prolific Twitter user), or become a Delegate yourself; opportunities are there and they are real.
This morning, I met Ray. Not in person, but through the beautiful network that is social media. His story was posted by a pediatric physical therapy colleague, and was so moving for me that I wanted to share it here. Ray’s video tells the story of a child who – like all children – wants to participate in life with his family and friends. He has spinal muscular atrophy, a rare degenerative neuromuscular disease. He will not get better, but Ray’s family simply wants to make him the best he can be for as long as he can be. They need help funding an addition to their house so Ray can use his power wheelchair to move around his home and play with his brother, Ethan.
I have had the privilege of knowing many children like Ray, and I have seen the difference that mobility makes in their lives. I have also experienced firsthand the frustration families face when trying to fund the equipment (including special vehicles, ramps, and home additions) needed to provide their child with the simple freedom that almost all of us take for granted – mobility. Want to help give Ray freedom? Click here: http://homefreehome.org/our-projects/build-freedom-for-ray/
I’ve got Twitter on the brain.
Today I’ve been putting the finishing touches on a manuscript describing research I did using Twitter in my Professional Interactions course last year. And I’m gearing up to start a new Twitter project with the same group of students when they go out on their clinical internships starting Monday.
I am passionate about using social media in physical therapy education. I believe it is a professional technical competency that all physical therapists should possess. I believe the next generation of health care consumers will demand that providers have a social media presence. I believe it gives us the opportunity to share our profession with the world and a means to write our own online story. I believe – as Dr. Natasha Burgert said in a recent seminar I attended – that my social media presence gives me the opportunity to amplify positive health care messages and drown out the bad ones. I believe reading social media makes me smarter and more humble. I believe that using social media as a professional makes me a better digital citizen, and that teaching my students to be better digital citizens is part of my job as an academic faculty member.
But sometimes it is hard to convince the nonbelievers.
Make no mistake, while I believe in the power of social media in health care and education, I get that social media isn’t something that everyone enjoys. I do not believe that all “good” health care providers should blog, tweet, and post. In fact, it’s probably a good idea that some of them don’t. I believe there is as much (if not more) value in “lurking” as there is in creating content. And I believe that it is enough for some providers to simply have the knowledge that there are conversations happening online, even if they rarely join those conversations. But, these days, I don’t think ignorance is an option.
Starting next week, I will ask a group of students to use Twitter to talk to me, each other, and the world while on their clinical internships. And about a month later, I will ask a brand new group of physical therapy students to tweet about their new role as a health care professional. You may assume that because these students are young (most are in their mid-20s), that they are social media power users. That they “get” Twitter and are ready to go forth and tweet as health care providers.
You would be wrong.
All of them use social media (mostly Facebook) in their personal lives, but many are still not ready to make the leap to using social media for professional communication. As with any group of people, there are power users who are eager to jump in. But there are also students who are completely uncomfortable with using social media in a professional manner. Some of them are private and don’t want to open a Twitter stream to the world. Some of them don’t yet have the confidence to put their knowledge out there for the Twitterverse to evaluate. And some don’t want to do it because it’s just one more thing to do.
I get it.
But I want them to get that there is a method to my madness. That I’m not just using technology for the sake of it or because I think it’s fun. I want them to understand that I think using social media – whether they tweet or post daily or simply lurk occasionally – will make them better physical therapists. They can build connections and an online community. Reach out to patients and potential patients. Stay up-to-date on the latest health information. They will learn that these forums can provide enormous value, and they may even decide to start providing a little value of their own.
As I’ve spent most of the day reading and writing about social media in health care and education, I opened my Twitter stream and decided to click over to the Millenial Medicine Symposium hash tag (#MMed13) to see what conference-goers think the future holds. There happened to be a discussion on health care social media going on, and one tweet almost perfectly sums up the reason I use social media as a health care professional, and my reason for incorporating Twitter into PT education:
— Brian S. McGowan PhD (@BrianSMcGowan) April 26, 2013
When you participate in social media discussions, your world becomes bigger. You discover new information. You find an online community. You can use group think to solve problems. You gain new perspectives. You learn.
And I would add to Dr. McGowan’s tweet that learning is also influenced by how you concisely share what you are hearing. When you create a professional, thoughtful tweet or post, you’ve learned something in the process. You’ve analyzed information, taken it apart, and put it back together in 140 characters or less. You have grown and you have contributed and you understand that information in a way you never did before.
Health care social media can be an incredibly powerful tool, but it requires an open mind, some old-fashioned intellectual curiosity, and a little fearlessness.
I hope my students will give it a try.
During the spring semester, I get to introduce second-year DPT students to “normal” motor development as part of their Control of Human Movement course. I created this 5-minute video (starring my three boys: Max, Charlie, and Bobby) for my students as a quick review of motor milestones in the first year.
As I note in the video, motor development is a complex and individual process influenced by individual differences, environment, and even culture. What I present here is meant to be a quick review, and is certainly based on the study of motor development in WEIRD cultures. Do you know any children who developed differently than what is presented in the video? Or who may have even skipped one (or more) of the milestones discussed?