The Physiotherapist

How does physiotherapy work for children with SEN?

Most children with SEN and associated physiotherapy needs will have some problem with the way the network of 'wires' in their brain connects up. Ideally, this network becomes increasingly more efficient as the child problem-solves its way through developmental challenges. But if a child's brain is not as successful at reinforcing the most successful neural pathways, messages will travel along extended routes, increasing the time for processing, or information may not reach the required destination or may go to the wrong destination. Problems with this sort of development include developmental co-ordination disorder and dyspraxia .These children have more difficulty adapting their behaviour appropriately and thus may have difficulties with academic learning.

Fortunately the brain has the capacity to re-route connections, and physiotherapy (like occupational therapy) can help this in various ways.

We can work to strengthen muscles that have never been worked properly.

Isabel, for example, had low muscle tone. This meant she never tipped her pelvis back as she reached for her feet. This had affected the alignment of her pelvis and meant her abdominal muscles were overly long and weaker than average. The right exercises helped improve her muscular strength and alignment. Jake also had low muscle tone, and as a baby had spent more time sitting than moving in and out of the hands-and-knees position. Because of this his trunk muscles were shorter than average and he seldom twisted his body sideways. This made it difficult for him to carry out co-ordinated actions between the two sides of the body.

Physiotherapists can work to improve balance and postural control by improving a child's core stability and equilibrium responses. Sometimes we have to take children passively through motor patterns before they can do them by themselves and later automatically as the pathways in the brain forge new and more effective connections.

Physiotherapy assessment

An initial assessment involves:

• Establishing concerns
• Finding out background medical, developmental and family history
• Detailed evaluation of muscles and joints including strength, length, alignment; core stability
• Posture in sitting and standing; neuro-development including anti-gravity ability and co-ordination balance responses and gross motor skills. Specialist physiotherapists like myself would also evaluate sensory integration, writing, fine motor skills and visual perceptual skills
• Interpretation of findings taking early medical and developmental history into consideration
• Feedback to parents
• Advice about how we can help
• Decision with parent about plan of action.

Treatment by a physio

Treatment depends on what each child may need, and might involve advice and a programme to follow at home, or weekly treatment plus home programme, or perhaps an intensive course of treatment. Children can be seen individually or in small groups and may be seen in clinics, at home or in school. The length of time children will need to attend for physiotherapy depends on the age of the child, need, and practical considerations such as who else the child is seeing. The average length of time I would work with a 6-year-old who has developmental co-ordination disorder in my practice would be two to three terms.

Treatment is goal-directed and our aim is to improve skills needed for more successful learning.

Typical goals might be:

• to re-train writing so their hand doesn't hurt
• to improve posture so their back doesn't hurt
• to improve ball skills
• to help them use cutlery more easily
• to improve their strength and stamina so they are not so tired by the end of the day
• to improve their sitting posture by working to improve core stability
• to improve their visual tracking by working on balance and bilateral co-ordination

Many parents talk about a 'halo' effect from treatment and notice that is not just the goals of treatment that improve, but self-esteem and confidence, thinking skills and concentration. Going back to our tiered pyramid, this makes sense as consolidating those abilities in the lower tiers makes a stronger foundation for the higher tiers.

Most children really enjoy their treatment, even though it is hard work. Therapists are very good at adapting the activities to make them fun and always aim to develop the child's self-esteem and self-confidence. For some children it is the highlight of their week and they literally run in to the treatment room desperate to start. It is an opportunity for them to improve in a safe, empathetic environment where they can trust enough to risk success.

The best result for us is to hear a child cry excitedly: 'I did it!!!'

Sally Wright, MCSP, SRP, works with a group of paediatric occupational therapists and paediatric physiotherapists. The practice is based in London W8 and NW10 and specialises in helping children with neurological and neuro-developmental disorders. Tel: 020 8208 1361 for further information. 

The developmental framework 

Sally Wright, specialist in neurological and neuro-developmental disorders, explains.

Perhaps the clearest way of explaining physiotherapy is to look at physiotherapists' developmental framework of reference, which we use to work out where to start and what gaps need to be filled in children's learning.

Imagine a tiered pyramid. The top tier is academic learning, but it is supported by several underlying 'themes' of vital developmental tiers.

The bottom tier

Sensory integration is a complex neural process. It starts in the womb and is the process by which we process sensations, not just from our five senses, but also muscles (proprioception) and balance receptors (vestibular). All this information is registered, filtered and integrated in the brain to result in movements becoming more and more refined and appropriate. It is a normal process, ongoing throughout life, but is particularly active in children up to the age of 7 years.

Second tier

Reflex maturation, refinement of balance, posture, postural organisation and motor planning. This develops as a result of the child's active interaction with their physical environment and through active problem solving. For example, a child has to 'work out' how to climb up onto the sofa and it is through this working out that new neural connections are made and reinforced. Of course some children with special educational needs can't work out how to do this by themselves and they may need to be taken through the movements first - this is something we may do as part of physiotherapy treatment.

Third tier

Awareness of the two sides of the body involves developing a preferred hand, learning to co-ordinate the two sides of the body together in actions and learning to co-ordinate the eyes and hands - in other words more sophisticated refinement of motor skills.

Fourth tier

To interpret information we see and hear we need to develop our visual, spatial and auditory perceptual skills. Children start to be able to make abstract judgements about things, such as recognising a cube just by seeing it because earlier they have handled the cube and looked at it from various different angles.

Putting it all together

In reality these tiers are not separate, but rather a jigsaw that gradually fits together as the baby learns to overcome gravity, walk, negotiate its environment and handle tools and toys successfully. Physiotherapists work mostly in the first, second and third tiers of this developmental pyramid.

Sensory integration is both a theory and a treatment approach and is used by both paediatric physiotherapists and paediatric occupational therapists. We believe sensory integration is the fundamental foundation from which all learning arises.

Integrating sensations are basic prerequisites for successful academic learning, because it means that children can:

• sit still
• shift attention appropriately
• make sense of what they see and hear
• develop a preferred hand
• develop fine and gross motor skills to a good enough degree, for example, to control a pencil

Children need to be posturally and emotionally secure so that they can attend to instructions and concentrate on what they have to do. They should also have acquired some basic organisational skills. Children who haven't mastered these fundamentals find themselves at a disadvantage in the classroom.

Why do children have these problems?

Some have a recognised genetic disorder, some have suspected genetic disorder, but as yet unrecognised, while others have suffered some form of brain damage or brain abnormality. This can be genetic, or due to complications during pregnancy, birth or after the birth. Poor feeding can be an indicator of future difficulties, as can excessive crying, irritability or poor sleep patterns.

The good news is that there is always something positive that can be done to help your child, and a physiotherapist with the right area of specialisation can contribute to that.

General information about physiotherapists

All NHS hospitals have a paediatric physiotherapy department, which can be accessed via referral through GPs or medical consultants. Private physiotherapists can be accessed directly by parents, but most will notify the child's GP or consultant as best practice.

Most children with SEN will need to locate a physiotherapist with neuro-developmental experience.

Physiotherapists with this specialised expertise work with many children who have cerebral palsy, developmental delay, prematurity, Down's syndrome and similar conditions. We are trained to assess muscle tone, muscle strength, muscle balance, posture, balance, co-ordination and neuro-development. We work to develop the background posture, alignment and balance the children need to carry out all motor skills. By guiding children's muscular and neural development along the right path we aim to prevent later problems as well as helping to put right difficulties that have already arisen. We'll work on components of skills and then integrate these into skills training. One important benefit of building up children's physical confidence is that they gain self-esteem too.

More specialised paediatric neuro-developmental physiotherapists work with children who have dyspraxia, developmental co-ordination disorder (DCD), dyslexia, Asperger's syndrome and related conditions. These physiotherapists are likely to be trained in sensory integration and may extend their work into the top two tiers of the pyramid. At this level of specialisation there is a degree of overlap with paediatric occupational therapists.

Finding a physiotherapist - questions to ask

Are you a chartered physiotherapist? Chartered physiotherapists will have MCSP (Member of the Chartered Society of Physiotherapy) and SRP (State Registered Physiotherapist) after their name. This means they will have completed a recognised undergraduate training and will be properly insured to carry out physiotherapy work.

What experience have you had working with children with (describe your particular child's difficulties)?
All children with special educational needs will need a physiotherapist with paediatric experience, but not all need highly specialised paediatric physiotherapists. It depends on the complexity of the case.

What tools/frameworks of reference do you use in your work? All paediatric physiotherapists will use a developmental framework of reference, but some may also have training in sensory integration.

Of course you need a physiotherapist with the relevant paediatric and neuro-developmental expertise but, as with any form of therapy, you need to feel that they have a highly positive attitude and a personality with which both you and your child feel confident and secure. The relationship your child develops with a therapist is very important, especially if there are also emotional difficulties.

For your part, physiotherapy will probably mean not just fitting in sessions with a therapist, but working through or encouraging your child with a programme of exercises between visits. Much of the benefits of physiotherapy come from repeated practice!

Further reading

The Occupational Therapist

The Educational Psychologist 

The Music Therapist

Nurture Groups

Dyspraxia Introduction - More than just a clumsy child?

Dysgraphia - Difficulty Writing

Neuro Diversity - Thinking Differently

Getting An Educational Psychology Assessment

The Orthoptist

The Special Educational Needs Coordinator (SENCo)

The Speech And Language Therapist (SALT)

Teaching Assistants

SEN In The Classroom

The Good Schools Guide - Special Educational Needs (2008)