Advanced Gross Motor Skills in Children

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bike

gallop/skio

Introduction

The child begins pulling himself to standing in his crib at about this time (7 to 8 months). At first, this is accomplished by using the newly developed strength of the upper extremities, while the lower extremities remain essentially passive. Once standing, the child will frequently hold onto the crib rails for support while he bounces and experiments with this newly discovered standing ability. During his earliest attempts at supported standing in the crib, he finds that he is unable to get down. Lowering himself slowly to the mattress requires strong eccentric control of his hips and knees, something that he has not developed. Frustrated and tired of standing, he may simply let go of the crib rails and drop to sitting, thanks to gravity, or he may begin to cry, signaling to his parent his need for help. A parent will come and either take the child from the crib or put him down inparagraph about transitioning to walking

7 Months

At 7 months, the child can only stand and walk with their hands held. The necessity for external support is due to their underdeveloped balance responses and poor anterior-posterior weighbearing alignment. Gait at this age is marked by a wide base of support with moderate abduction with hip external rotation and pronated feet. The amount of pronation correlates to the amount of abduction and external rotation of the hips. Children at this state will walk with their hip and knees flexed.

Pull-to-Stand

Around 10 months old, the child is able to pull themselves up to standing using a low table or sofa. From this position, the child is able to get down to the floor with control. The process of pull to stand moves through tall-kneeling and half-kneeling.

• Tall-kneeling:
  • weight on both knees
  • wide base of support
  • use of upper extremities to pull up
• Half-kneeling:
  • shift weight to one side
  • elongated trunk on weight shifted side
  • unweighted leg moves forward to place foot flat on floor
  • use of hip and knee extensors to facilitate moving against gravity

Moving back to the floor uses the same half-kneeling and tall-kneeling positions. Initially these movements may be them letting go and quickly dropping to the floor. With time and practice, these movements will become very quick and controlled.

Cruising

Once the child is able to pull-to-stand, they will play for long periods of time squatting and standing moving back and forth between furniture and floor. The new skill allows the child to squat to play and to pick up toys from the floor and place on the sofa. Squatting becomes both a posture in itself and a transition movement between postures. As the child moves from squat-stand-squat, co-contraction of the ankle musculature occurs enhancing stability.

Around 10 months old, children will begin stepping sideways holding furniture for support. This supported lateral movement is referred to as cruising, With this newfound mobility, the child is able to work their way along the furniture and eventually able to reach other pieces of furniture in an effort to navigate the room. Cruising gait exhibits less hip and knee flexion and better anterior-posterior alignment. Balance is improved during this time as the child is able to lift one supported hand and rotate their body. They may even take 1-2 steps without support from either upper extremity. Cruising helps the child to strengthen their lower extremity musculature specifically the hip abductors/adductors and ankle evertors/invertors. At 10 months of age, the plantar grasp reflex may still be present although considerably diminished. Complete resolution of the reflex is necessary for independent unsupported walking to develop.The child will eventually stand independently letting go of their upper extremity support from furniture or an adult. When this occurs, trunk stability is maintained by a high guard position of the upper extremities.

Bipedal Locomotion

Between 10-15 months old, children begin to walk independently with the average age of 12 months.

Early Independent Ambulation

• upper extremities in a high guard position
• adducted scapulae
• hip and knees flexed
• abduction and external rotation of the hips
• wide base of support
• pronated feet
• no heel strike

Gait Progression 1

• upper extremities in low guard position
• elbows flexed
• hands just above waist and stabilised against the body
• fingers pointing upwards
• shoulders adducted

Gait Progression 2

• upper extremities in shoulder extension and hang at child's side
• reciprocal arm swing
• increasing hip and knee extension
• decreased hip abduction
• decreased external rotation of the hip
• narrowing of base of support
• neutral pronation/supination of the feet
• heel strike, push off

Gait Parameters

Over the next 2-4 years, gait will continue to improve. Gait parameters such as cadence, step and stride length and velocity will change as they grow and mature. During initial independent walking, cadence (the number of steps per minute) begins very high and decreases as they age. A one-year old spends very little time in single limb stance due to lack of strength and stability in their hips. Therefore, this decreased time increases the amount of steps for a one-year old compared to a 3 year old who can spend more time in single limb stance. A child's gait velocity (distance covered over a specified amount of time) begins low and increases with age. Velocity is correlated to the length of one's stride or step. The measurement from heel strike one one foot to heel strike on the opposite foot is referred to as a step. Stride, on the other hand is measured from heel strike on one lower extremity to heel strike on the same extremity. Stride length is roughly twice the step length.

From 1 to 3 years of age, a child’s step length and stride length increase, as do velocity and single limb stance time.109 Single limb stance increases with increasing strength and balance abilities. Length of step and/or stride, and therefore gait velocity, increases as the child’s lower extremities continue to grow in length, even well after age 3. Otherwise, gait at age 3 is considered to have parameters similar to those of an adult.109 Various gait parameters at ages 1 year and 3 years are shown in Table 2.5. Even though a toddler is able to walk fast, and his parents will often insist he is running, true running does not develop until 3 to 4 years of age. A true run is characterized by having both feet off the ground at the same time, unlike walking, where one foot does not leave the ground until the other foot makes initial contact. Stair Climbing Stairs present a considerable challenge to toddlers, as one might imagine. The typical rise of a step in a flight of stairs is 7 to 8 inches. For a 15-month-old child to negotiate stairs in erect standing would be the equivalent of an adult attempting to climb stairs with a knee-high rise (Fig. 2.72). The ability to ascend and descend stairs is affected by a number of factors, most particularly, opportunity. Therefore, the age of achieving this milestone has considerable variability, although the sequence of achievement FIGURE 2.72 Descending stairs with hand held; note the rise of the step in relationship to the length of the child’s lower extremity. Gait Parameter 1 Year of Age 3 Years of Age Direction of Change Base of support (pelvic span to ankle spread) <1 ≥1 ↓ Step length 20 cm 33 cm ↑ Stride length (double the step length) 40 cm 66 cm ↑ Single limb stance 32% of gait cycle 35% of gait cycle ↑ Cadence (step frequency) 180 steps per minute 154 steps per minute ↓ Velocity (speed) 60 cm/sec 105 cm/ sec ↑ a From Long TM, Toscano K. Handbook of Pediatric Physical Therapy. Philadelphia, PA: Lippincott Williams & Wilkins; 2001. Gait Parameters in 1- and 3-Year-Old Childrena TABLE 2.5 58 Part I Development. is much the same from one child to the next. A child who lives in a home without stairs, or at least without stairs that the child is permitted to climb, often develops stair-climbing skills at a later age than the child who has frequent daily encounters with stairs to get to and from his bedroom and/ or toys. The first ability to ascend and descend stairs is usually in the quadruped position (Fig. 2.73). The child learns to go up the stairs on his hands and knees, followed soon by coming down the stairs backward on his hands and knees. Sometimes children, in their first attempts at descending stairs, will try to do so in quadruped, but head first, with disastrous results if a caregiver is not nearby. With a bit of coaching, the child quickly learns through trial and error to descend the stairs backward on his hands and knees. Ascending stairs generally develops to a more skillful level before descending stairs develops to the same level of skill. This sequence generally repeats itself in bipedal locomotion after the child has developed the ability to go up and down stairs using quadrupedal locomotion. Another feature of stair climbing that develops in a rather typical pattern is apparent once the child is climbing stairs while standing. Initially, bipedal stair climbing is performed by placing both feet on each step, in a manner that is called marking time. 48 Generally, the child will not begin doing steps one over one. (i.e., only one foot to each step) until he is close to 3 years of age, depending of course on how much trial and error and practice on stairs he has been afforded. This pattern of the feet is also dependent on the type of upper extremity support that is available. Stair climbing progresses as the upper extremity support decreases from using one handrail and/ or an adult hand for support, to needing a handrail but no adult, and finally to needing no upper extremity support (Fig. 2.74). Of course, the speed with which the child develops increasingly more skillful stair-climbing abilities varies greatly, and like other skills, the ability to locomote on stairs may temporarily digress as unique and/or challenging circumstances, such as unusually steep stairs or the absence of a handrail, present themselves.