HANDLING AND POSITIONING
Physical preparation of the child for efficient
feeding in therapy or at mealtimes, is critical to the
success of the program. This paper offers a series of
questions and observations that will help therapists and
parents provide a good physical foundation for improved
feeding and oral-motor skills. An understanding of the
relationship between the body and mouth is the first step
toward making changes.
OBSERVE THE TRUNK.
What is its tone? What is the stability of the trunk? Is
there symmetry, or does the trunk pull down more on one
side? Problems with the trunk can lead to compensations
and tension in other parts of the body. Poor trunk
control leads to poor head control since the neck needs a
stable support surface for precise control.
OBSERVE THE HIPS AND PELVIS.
Forward or backward tilting of the pelvis in sitting or
standing can influence head control, breathing, voicing,
and mouth control. This occurs through action on the
spine and the child's attempt to compensate for the
imposed spinal curve or position. Full extensor spasms of
the spine often begin with thrusting back of the pelvis.
This creates major problems in the shoulders, head and
mouth while the child is sitting.
OBSERVE THE SHOULDER GIRDLE.
If the two scapulae (the shoulder blades) are adducted
(pulling toward each other), the shoulders will pull back
into a retracted position. This retraction causes a
tension which often pulls the neck into hyperextension
and influences the pattern of lip, tongue, and jaw
retraction. If there is scapular adduction the child will
have difficulty getting hands to the mouth, putting the
hands together, and reaching for a toy.
OBSERVE THE RELATIONSHIP OF HEAD CONTROL AND SPINAL
Head control is mediated through the entire spine. An
active, flexible spine enables the entire vertebral
column to do the work of head control. When the spine is
rigid or fails to respond as a coordinated unit, head
control must be achieved by the neck alone. The muscles
of the cervical spine (neck) are not strong, and they
fatigue easily when they must take full responsibility
for maintaining the head in an upright position. When a
child is positioned or strapped into a tightly-fitting
chair or corset so that spinal movement is impossible,
the full spine cannot assist in head control. If such
positioning is necessary to provide assistance with trunk
control in school or for transportation, therapy should
include activities which will develop mobility and
control through the entire spine.
OBSERVE THE ABILITY TO MOVE AROUND THE BODY AXIS.
Freedom of movement implies the ability to combine and
integrate both flexor (bending) and extensor
(straightening) components of movement. This ability
enables smoothly graded movement with small steps and
transitions. In perfecting an activity such as the
development of trunk control, the infant initially
develops control of the extensor component (such as
lifting the head from tummy-lying). Control of flexor
movements is added as the baby lifts the head when raised
from back-lying to sitting. The development of lateral
and diagonal movements requires the smooth coordination
and integration of both flexor and extensor movements.
The infant perfects these combined movements in rolling
to the side, and in rolling from tummy-to-back and
back-to-tummy. These sequenced movements occur in smooth
transitions around the central axis of the body. It is
important to work on these aspects of movement in the
development of full head and trunk control.
OBSERVE THE ABDOMINAL MUSCLES.
The abdominal wall is composed of a series of muscle
groups whose fibers run vertically, horizontally and
diagonally. These muscles provide the major contribution
to the development of trunk control. As the control of
the abdominal muscles emerges at 5-6 months, the baby
includes lateral trunk movements and the diagonal
movements needed for rotation in sitting and rolling.
Activation of these muscles creates a retraining wall to
support the abdominal contents. This reduces the stress
on the stomach valves and decreases the amount of normal
spitting-up which the infant does. The abdominal muscles
also hold down the lower border of the rib cage, enabling
greater activity of the intercostal muscles and deeper
chest breathing. Controlled activation of the abdominal
muscles is required for vocalization which is loud and
sustained. Relaxation of the extensor muscles of the
lower back and pelvis occurs in combination with the
abdominal movement. The treatment program should include
activities to obtain activation and coordination of these
muscles of the abdominal-pelvic girdle. The muscles may
be stimulated by touch or pressure and by slow movement
in all directions.
OBSERVE FOR ORIGINAL PATTERNS AND COMPENSATIONS.
The movement behavior that one sees in an older infant or
child is usually a mixture of the original pattern
imposed by the brain damage, and the child's response to
that pattern. The underlying picture in the young infant
is usually one of low tone with trunk instability. As
tone develops, extensor tone is the first to emerge (as
in normal infant development). The infant's response to
the low tone combined with extensor tendencies is to
counteract the pattern with a holding or fixing movement.
As this fixing becomes stronger, movement is curtailed in
those parts of the body involved in the fixing. These
blocks to movement are seen predominantly in the neck,
shoulder girdle and pelvis. The child unconsciously uses
other movements to compensate for lack of movement in the
blocked area. Thus, if a child is locked with the pelvis
tipped posteriorly in sitting, he is in danger of falling
backward. If he has some control of the trunk, he may
round the upper spine forward to remain upright. Through
this compensation, they may develop a strong pull-down
into flexion in the pectoral muscles of the chest and
shoulder girdle. He may, furthermore, need to tip the
head into hyperextension in order to use the eyes
effectively. In treatment it is important to identify and
treat the underlying pattern rather than focusing on the
compensation. One can never successfully take a
compensation away from an individual unless a better
movement or control pattern has been provided.
OBSERVE EYE CONTROL SKILLS.
Can the child maintain focused eye contact with an object
or face? Can she track in all directions? Problems with
the control of eye movement can influence how a child
holds the head. Tilting of the head into extension or to
one side may be a compensation for inadequate focus or
movement of the eyes in one or more directions. Work on
eye control is most successful if the child is lying in a
supine position (on the back) with the head slightly
elevated. Since demands are not placed on the child for
maintaining head and trunk control, it is easier to
separate out eye movement. The therapist can explore the
child's abilities to sustain eye contact with a toy when
it is held at different distances from the face. Work on
tracking or following movements can be done in two ways.
The child can hold the head still in midline and move the
eyes to follow the object. Separation of eye and head
movement can also be achieved through asking the child to
keep the eyes on the stationary object as the head is
turned slowly to the side or in an upward or downward
OBSERVE THE SITTING BASE.
If the child's base for sitting is narrow, a greater
amount of trunk control is required. The child who lacks
adequate trunk control will have greater problems if the
legs are close together (adducted ) in sitting on the
floor or in a chair. The separation of the legs by an
abduction wedge or pommel can widen the sitting base,
allowing the child to use a more limited amount of trunk
control. The use of W-sitting by many children is a
compensation for poor trunk control and inadequate
balance reactions. The child learns that the wider
sitting base created by the W-position of the legs
increases her security and steadiness, allowing for
greater freedom in play. The focus in treatment should be
placed upon building greater stability and control of
trunk movement, greater rotation and movement in and out
of side-sitting, and improved balance reactions.
OBSERVE INTERACTIONAL ASPECTS OF POSITIONING.
Does the positioning or type of handling that you have
selected maximize the child's opportunities for
interacting and communicating? What must the child do in
order to see your face? What choices does the child have
to indicate discomfort or desire for a change in position
or activity? Is the child a true participant in the
treatment session, or is he expected to comply with the
therapist's instructions? When the child feels
manipulated or disrespected, tense physical patterns are
often elicited as a type of communication.
OBSERVE THE USE OF YOUR BODY.
The therapist, educator and parent should become aware of
their personal use of movement. Where handling of the
child is effortful or tense, the child receives the added
message from the adult's body that movement is difficult,
that efforting is appropriate or that the adult is
coercive or uncertain of the child's response. An
awareness that efficient, gentle and rhythmical movement
from the adult will increase the likelihood of easy
movement from the child should be developed. The adult
body can also be used as an initial piece of equipment to
assist the development of skills such as tummy-lying,
sitting, or standing. For example, the shifting of weight
in sitting or the use of propping forward on the hands is
much more interesting for the child while sitting astride
the adult's abdomen or waist, than when sitting on a roll
or ball. Work on head control in prone can be done with
the child lying on the parent's abdomen and chest.
Assistance can be given at the shoulder girdle or pelvis
to assist with the maintenance of head lifting and
support on the forearms. Because the child is in physical
contact with the adult, and is able to interact freely
with the eyes and face, the motivation for keeping the
head upright is high. The child perceives the activity as
interactive and playful rather than something which must
be done to please the adult.
OBSERVE THE ROLE OF EQUIPMENT IN THE SESSION.
Equipment can be used effectively to maintain a movement
pattern or posture with which the child is familiar and
comfortable. It should not be used to create or achieve a
new movement pattern. Thus, the child is prepared for
sitting in a specific chair through handling on the
therapist's lap or straddling a roll. Familiarity with
weight-bearing through the hips, legs and feet is
provided through work from a ball or a lap before placing
a child in a prone stander. Even when a child has
experienced the sensations involved in standing or
sitting, it may be necessary to prepare her for placement
in her chair or prone stander prior to it's use in a
therapy session or classroom. Preparation for use of a
chair for feeding or a prone stander for a learning or
language activity in the classroom may be done in a
therapy session immediately prior to the use of the
equipment in the classroom.
The word, facilitation means "to make easy".
Specific sensory input through touch, movement,
temperature, pressure, hearing, and vision can allow a
child to experience a new, easy movement pattern.
Facilitation implies that the nervous system contains
patterns and possibilities for improved sensation and
movement that are not typically used by the individual.
In order to use facilitation concepts effectively,
attention must be paid to the tone and movement patterns
that have limited the child's spontaneous development of
skilled movement. These patterns are curtailed by
reducing the type of sensory input that usually elicits
them. For example, if the child's head is turned strongly
to the right side, the body may assume the stereotyped
movement pattern and tone of the asymmetrical tonic neck
reflex (ATNR). The limbs on the face side may be extended
while those on the skull side are flexed. If the
therapist reduces neck extension and brings the head to
midline, the brain no longer receives the stimulation to
the proprioceptive receptors in the neck that trigger the
ATNR. As the child's system is freed from the influence
of this movement pattern, stimulation to the righting
reactions will enable the child to experience a new type
of head control. Through facilitation the therapist helps
the child create and experience a new sensorimotor
pattern. As this new pattern is repeated, it becomes
familiar to the child. The new pattern can then be
compared with the old limiting or inefficient way of
moving. The child must have a clear sense of how these
movement patterns are similar and different. The
therapist assists the child in learning how to move
between the two patterns. Verbal comments can be added
which will give the child a clearer frame of reference.
For example, one movement could be described as
"stiff" and contrasted with a "soft and
easy" movement. Words that are descriptive rather
than evaluative can be selected. When the therapist
describes the movement a s "your bad voice" or
your "good voice", the focus is shifted from
the description to the inner judgment of acceptance and
adequacy. It is the child who ultimately decides which
voice or movement pattern provides the greatest pay-off.
It is not enough to handle the children so that they
experience normal tone and movement. When the adult is
not with the child, or when more challenging activities
are attempted, the habitual patterns will return.
Children must have a bodily understanding that will
enable them to switch to the more efficient pattern
independently. They need to know how to get unstuck when
they feel stuck in the old movement pattern. A major
emphasis in treatment should be placed upon the
transitions between movements rather than on the
achievement and maintenance of a static posture (such as
sitting or prone-on-elbows).
Teamwork implies a sharing of the knowledge and insights
of different individuals who work with a child and
family. Frequently the concept is implemented through
formal meetings designed to allow all professionals and
the parents to know the current components of a child's
program. This may be followed by a discussion that
results in specific changes in the emphasis or components
of the total program. Teamwork can also be a
joining-together and sharing of knowledge and insights.
The physical or occupational therapist may be more
comfortable with needs for positioning and handling than
the classroom teacher or speech-language pathologist
whose professional training has placed less emphasis on
movement. When these skills are shared with others who
are less comfortable with the movement aspects of
treatment, all will benefit. The teacher can contribute
appropriate ideas for the development of cognitive and
academic skills. The speech-language pathologist can
enrich classroom and PT-OT sessions through sharing ideas
and insights for the enhancement of communication and
Teamwork involves a sharing of oneself. This implies
the free giving of knowledge, skills and insights without
the need for their acceptance by the other person. When
the individual offers suggestions based on an inner
attitude of criticism and judgment of another's ability,
judgmental and critical feelings will prevail. A learning
environment of acceptance and freedom provides the
foundation for integration of new information, for change
and for creative problem solving. When suggestions are
made with the expectation that they will be implemented,
a sense of demand prevails. Demands provoke resistance.
Suggestions offered in an environment of interaction and
freedom are evaluated more openly since the issue of
expectation is not involved. When the individual's sense
of personal worth is separated from the results of
treatment or suggestions, the situation can be assessed
Evans Morris, Ph.D.
1124 Roberts Mountain Road
Faber, Virginia 22938
This paper is a working
draft and multiple copies may not be reproduced
without prior written permission of the author
© Suzanne Evans Morris, 1997 All Rights Reserved