Physiotherapy and Dyspraxia

By Michele Lee, Grad. Dip. Phys. MCSP. SRP.

Michele Lee is a Chartered Physiotherapist in Paediatrics, based at the Lee Medical Practice in Buckinghamshire. She is Chair of the Dyspraxia Foundation and is widely respected as one of the foremost authorities on physiotherapy and dyspraxia.

What is a Paediatric Physiotherapist?

Most people have heard of physiotherapy in relation to helping with sports or back injuries. The physiotherapist in these situations has improved the pain and muscle strength and restored normal movement. The Chartered Society of Physiotherapy describe physiotherapy as �a health care profession with an emphasis on the analysis of movement based on the structure and function of the body and the use of physical approaches for the promotion of health, and the prevention, treatment and management of disease and disability...� These principles apply to the treatment of both children and adults. Paediatric physiotherapy has been described by the Association of Paediatric Chartered Physiotherapists (A.P.C.P) as the �treatment of any childhood condition whether acute or chronic by physical means (eg: exercise, heat, ice and massage) which threatens physical development and therefore may reduce full potential for adult independence�.

Paediatric physiotherapists undergo a formal training in physiotherapy to a degree level and general experience before embarking on postgraduate training to work in paediatrics. There are many fields open to a paediatric physiotherapist and some further specialise into fields such as respiratory, orthopaedics and neurology. Physiotherapists who treat Dyspraxia will have carried out training in neurology so they have a good understanding of normal child development and normal movements. This gives them a sound basis in order to appreciate why children with Dyspraxia have difficulties and what physiotherapy can offer to improve the children�s difficulties.

The Dyspraxia Foundation defines Dyspraxia as �an impairment or immaturity of the organisation of movement�. This difficulty with planning movements has also been described by Cermak (1991) and Ayres (1979) in their definitions of dyspraxia. Cermak in fact defines dyspraxia as �a difficulty in planning and carrying out skilled, nonhabitual motor acts in the correct sequence�. Dyspraxia is also frequently used to describe children who have difficulty in daily activities that require co-ordination of movement that is out of proportion to the child�s age and intelligence. As a result of these difficulties, it is a condition which threatens physical development and may reduce the child�s ability to reach her/his full potential. Physiotherapy aims at improving the quality of movement both with the planning and carrying out of movements. This is achieved through exercises, games and activities.

The Importance of Movement

Motor development influences intellectual, social and emotional development. Through play a child will learn and practice her/his gross motor skills and co-ordination skills until s/he perfects them. Through play with peers a child learns social skills including the concept of giving, taking and sharing. Exploration of the environment leads to knowledge about the child�s world and to the formulation of basic concepts, e.g: under/over, up/down; which will later be used learning basic academic skills (Lee & French, 1994). These factors in turn lead to self confidence and a positive self image. Children use their previous positive experiences to attempt new tasks and explore new areas without being threatened with failure. It can be seen that movement is the basis for learning and where there are limited or impaired movement skills, as is the case for dyspraxic children, problems arise and escalate as the child grows older (Lee & French, 1997). The dyspraxic child has many negative experiences and feels threatened by failure. S/he frequently fails with new activities. This in turn leads to poor self confidence and self image. This forms the most important aim of all treatment. Self confidence and self esteem must be improved so the child can build on positive experiences and feel s/he is achieving

sitting generally achieved between 6 - 9 months
crawling generally begins to be achieved at 9 months
standing generally achieved by 12 months
walking usually achieved from 12 months
running a child usually runs safely by 24 months and well by 30 months. Can run slightly on toes from 5 years
jumping at 30 months a child can usually jump from a low step
hopping achieved by 4 years
climbing stairs the child will go upstairs reciprocally (one foot after the other) at 3 years and come down reciprocally by 4 years of age.
riding a tricycle/bicycle a child usually begins to pedal at 2 years of age and is an expert by 4 years. Many children begin to ride a bicycle without stablisers from 5 - 6 years of age.
skipping usually achieved by age 5
standing on one leg most children can stand momentarily at 3 years of age. By 4 years for 3 - 5 seconds and by 5 years for 8 - 10 seconds.
throwing and catching balls at 3 years of age a child can throw a ball overhand and catch a large ball between extended arms. By 4 years they can use a bat.



Physiotherapy as part of a multi-disciplinary approach

Many professionals may be involved with the child with dyspraxia. These include the educational psychologist, paediatrician, G.P., teachers, occupational therapists, speech therapists, special needs teacher/tutor and orthoptists as well as the parents and the child. It is therefore important that everyone involved with the child liaises closely and works together to ensure a united and integrated approach. Equally important is that the child is not overloaded with different home programmes given by various professionals.

Why are children referred for physiotherapy?

Dyspraxic children may be experiencing a number of difficulties both within and outside the classroom setting. Some of the difficulties are listed below. Many children will not necessarily experience all the difficulties stated:

* Delay in reaching milestones. The following achievements have been well documented (Sheridan, 1973). Many parents report that their child did not crawl or did so for only a short period of time (1 - 2 months) as they became early walkers (e.g: 9 - 10 months).

* Poor writing and drawing skills - this may be related to the style and speed and immaturity of drawing pictures with poor detail

* Poor ability to sit still

* Generally disorganised. They often have difficulty planning activities/written work

* Frequently fall over or trip

* Messy eaters. Children may have difficulty using a knife and fork together and prefer to use a spoon or fingers; have difficulty cutting food and prefer to tear it. Frequent spillages.

* Poor at P.E and ball activities.

* Tendency to knock into furniture or people or stand very close to people and �invade personal space�.

* Difficulty with short term visual and verbal memory. (Often have very good long term memory!) This may manifest as difficulty copying from the board or text, difficulty following dictation or carrying out verbal instructions.

* Poor concentration. Easily distracted.

* Slow at dressing/undressing and often look untidy once dressed.

* Have difficulty making friends. Described as �loners�.

It is important to have some understanding of the skills that are involved with the activities that dyspraxic children have difficulty carrying out. The main element of the physiotherapist�s assessment will involve assessing these skills to determine whether the child is carrying them out either to an age-appropriate level or with the quality that would be expected. There are many skills that will be assessed. Some of the main areas are listed below and have been documented by Lee and French (1994):


* Shoulder control
This relates to the muscle strength and joint laxity around the shoulders. It is an important factor for hand function and a prerequisite for writing skills.

* Pelvic control
This relates to joint laxity and the muscle strength around the hips and is required for activities such as standing on one leg, hopping and kicking a ball. Together with shoulder and trunk control, it has an important role in balance. Children who have problems with balance will find it difficult to maintain sitting on a chair (let alone concentrate on fine motor skills such as writing). They may also be easily taken off balance by other children, especially in the playground situation.

* Eye-hand co-ordination
The ability of the hands and eyes to work together is required for activities such as walking over uneven surfaces, kicking, walking around obstacles and objects on the floor and for stairs.

* Midline crossing
The ability to cross one side of the body to the other side so going across the imaginary midline in the centre of the body (i.e: either an arm or leg from one side of the body to the other) is necessary for activities such as writing, and reaching.


* Directional awareness
The ability to move in different directions such as forwards, backwards and sideways is needed for writing, moving around rooms, etc.

* Spatial awareness
The ability to judge distances and direction of self in relation to other objects is needed to ensure that the child does not knock into things, or knock them over.

* Symmetrical integration
The ability to move both sides of the body simultaneously in identical patterns of movement are needed for activities such as jumping forwards, rolling a pastry roll and throwing and catching a ball with two hands.

* Bilateral integration
The ability to move both sides of the body simultaneously in opposing patterns of movement such as jumping sideways is needed for activities such as pedalling a bike and using a knife and fork.

* Body perception and proprioception
This includes body image - visual knowledge of yourself, your body scheme - sensory knowledge of yourself and body awareness - sensory knowledge of oneself moving through space. It is needed for drawing pictures of people, dressing, etc.

* Short term visual and verbal memory
As stated earlier, this is required for copying from the board or text; carrying out visual or verbal instructions and for dictation. It is also needed for the child to remember the sentences that s/he had constructed before s/he is able to get them written down.

* Motor planning
The ability to plan the necessary movements that are required to move from one position to another is needed for all activities such as getting up from the floor, climbing apparatus, all sports and activities including writing.

From the above information it can be seen that in order to write, for example, a child must have good shoulder control, hand-eye co-ordination, balance for sitting on the chair, midline crossing, directional awareness, spatial awareness. motor planning and short term memory. Similarly, the ability to eat well at a table will require good balance to sit on the chair, good shoulder control, hand-eye co-ordination, bilateral integration, spatial awareness, body perception and proprioception and midline crossing. Likewise, activities in P.E require all the above skills.

The Assessment

It is usual procedure that prior to the assessment, parents and often teachers are sent a confidential questionnaire. This ensures that no awkward questions are asked in front of the child and enables the physiotherapist to have a clear understanding of everybody�s concerns. Children are assessed to ascertain their difficulties and which areas can be helped with physiotherapy. A number of techniques are available to the physiotherapist which include standardised tests which are objective, may aid diagnosis and can record progress and outcome. In addition, the Physiotherapist will also carry out a number of observations to identify the child�s strengths and weaknesses and how the child is able to carry out the tasks. The child is made to feel relaxed and to enjoy the session as the assessment enables to physiotherapist to establish a relationship with the child and family. Following the assessment, goals are made that the physiotherapist would like to see the child achieve by the end of treatment. These are related to the skills that had been noted to be poor. Scores are set that the child should reach. The parents and often the child also set goals or tasks that they would like to see achieved. These may include improved ability to write, improved ability with P.E., avoiding knocking into objects or tripping over.

The Treatment

There are many forms of treatment. Generally children are seen on a weekly basis for 8 weeks (Lee & French, 1994., Lee, 1996), and treatment is supplemented by a daily home programme which takes no longer than 15 - 20 minutes to complete. The importance of the home programme cannot be stressed enough as it is through this that skills can be practiced regularly and acquired and muscle strength can reach its maximum potential. The treatment generally consists of exercises to improve muscle strength and activities and games to improve skills. Most physiotherapists prefer that parents are not only present but partake in the treatment sessions. Skills are broken down to a level that the child can achieve so that confidence is improved and then can be built upon. Many physiotherapists will use games that are from retail toy shops so the child can easily identify with them. The emphasis is based on the sessions being fun and enjoyed by the child as this will encourage the child to learn and encourage participation. Most children are initially treated on a one-to-one basis as this will assist with concentration and confidence. Some centres treat in small groups in order to encourage social skills and awareness of others. Close liaison with the school is vital so the teacher can be given advice on management within the classroom and P.E setting. Many of the activities used in treatment can also be carried out in P.E. It is important for all those involved with the child to understand that the child needs time to practice and master skills.
Following treatment children are usually reviewed 3 months after the completion of treatment to ensure that the progress made has been maintained and the long term aims and goals set by the parents have been reached.

Long Term Management Programme

It is vital for both the child and parent that following treatment and the review, a long term management programme is made. This includes carrying out a check list regularly to ensure that the progress made with the skills and muscle strength is maintained and any difficulties can easily and quickly be identified. Advice is also given on regular sports in addition to those carried out in school to ensure that newly acquired skills are practiced and strength continues to be maintained. Swimming is frequently encouraged as is football and tennis training. Most children will suggest sports that they have a particular interest in and these may include rowing, Judo, cricket and activities such as chess. Children should be continued to be monitored on an annual basis to ensure that progress is maintained, the check-list can be updated and continued close liaison with the school is recommended. This is of particular importance at the start of a new school year when new staff may be involved or with a change of school.


Effectiveness of Treatment

Physioterapy treatment has an effect on the gross motor skills, ball skills, fine motor /manual dexterity, activities of daily living and on self confidence and self esteem. There have been several published reports on the effectiveness of physiotherapy treatment in England (Norton & Twentyman (1995), Lee and Smith (1998), William, Smith & Ainsley (1999), Lee & Smith (2002)). These authors reported an improvement with treatment, and included children having been treated in a group or on an individual basis. Lee & Smith (1998) showed objectively that the children treated on an individual basis made on average 69% improvement with their gross motor skills immediately following treatment. By the review which took place 3 months later, the children had continued to progress, with each child on average making 73% improvement with their gross motor skills and parents reported an improvement of 72% on average with the activities of daily living. Lee & Smith (2002) also showed that these children had generally maintained the improvement with their scores over 3 years although 20% had required one further course of treatment. In their article, Lee & Smith also reported that the children were more willing to attempt new activities, had more friends and were generally more confident. 

Lee , Yoxall and Smith (2002) carried out an audit of 25 children who received physiotherapy treatment over an 8 week period and they tested the self esteem prior and following treatment using B/G Steem. Their results concluded that all the children had made progress and on average had improved their scores by 3.21 points. In addition, the parents of all these children verbally reported an improvement with confidence and self esteem.

Conclusion
Dyspraxia is a very rewarding and enjoyable field to work in and one that we as professionals can offer so much to help with. As public awareness improves and the condition becomes more recognised, more children will have the opportunity for help that they so desperately require. It is not a case that a dyspraxic child will be the next Ian Botham or Tim Henman, but they can enjoy and compete in sports. Physiotherapy focuses on the very skills that are required in sport and within the classroom setting although they will be of a more refined nature and will give the child an improved opportunity to learn and reach her/his maximum potential for adult life.




References

Standards of Physiotherapy Practice, Second Edition. (1993) [Chartered Society of Physiotherapy, U.K].

Physiotherapy in Paediatrics. (1990) [Assocation of Paediatric Charted Physiotherapy Publications, U.K].

Gisher A. G, Murray E.A, Bundy A.C , Editors (1991) Sensory Integration - Theory and Practice. [F.A Davis & Co, Philadelphia, U.S]. (See chapter by Cermak S.A Somatodyspraxia ).

Lee M & French J (1994). Dyspraxia - A Handbook for Therapists. [Association of Paediatric Chartered Physiotherapy Publications, U.K]. 

Lee M (1996). Setting up a Dyspraxia Physiotherapy Service. [Lee Publications, U.K].

Lee MG & Smith GN (1998) The effectiveness of Physiotherapy for Dyspraxia, Physiotherapy 84 (6) 276 � 284

Lee MG & Smith GN (2002) A three year study on the Progress of Children Following Physiotherapy Treatment for Dyspraxia .Dyspraxia Foundation Professional Journal 1: 9 � 23

Norton & Twentyman (1995), Group Therapy for Children with Co-ordination Problems. Association of Paediatric Charted Physiotherapists (75): 32 � 36


Sheridan M (1973). From Birth to Five Years. [NFER-Nelson Publishing Co., Ltd, U.K].

William, Smith & Ainsley (1999), . The Effects of a Physiotherapy Intervention Programme on Children with Developmental Coordination Disorder. Association of Paediatric Chartered Physiotherapists (91): 32 - 40