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Introduction to Post Walking Skills

6

Congratulations! If you are reading this section of the book, your child has learned to walk, and he is now ready for a whole new

period of exploration and gross motor skill development. It is time for him to be independent, have fun, gain confidence, and be proud of what he can do. Part Two of this book is about the Post Walking period of development, and the goal of this period of development is to refine your child’s walking pat-tern. This will be accomplished by practicing targeted gross motor skills, the post walking skills, and by providing customized foot support. This chapter is divided into three sections: post walking skills, foot management, and guidelines for this new period of development.

In Stage 5, your child learned to walk using the new walker pattern. Since walking independently is such a difficult gross motor skill to do, he figured out a method that was stable for his body, with his degree of hypotonia, ligamentous laxity, and strength. The new walker pattern of a child with Down syndrome (fig. 5.27) is similar to that of a one-year-old (fig. 6.1). Components include:

1. a wide base, with heels wider than hips2. feet turned outward or toeing-out3. weight bearing on the inside borders of his feet (with flat

arches if barefoot)4. full sole weight bearing when stepping, like taking

marching steps5. trunk vertical, trunk and pelvis moving as a unit, with

no pelvic rotation6. short step length7. stiff knees8. arms in the high guard position

292 ! Introduction to Post Walking Skills

Your child’s walking pattern may not have all of these components, but these are the areas to monitor. Through using this stable pattern, your child gained confidence in walking and learned to walk all of the time. Now that he is motivated to walk, and this is his established method of mobility, he will be comfortable with being challenged to refine his walking pattern.

The components that need to be developed for the refined walking pat-tern (see p. xi) are:

1. a narrow base with heels in line with hips2. feet and knees pointing straight ahead3. feet in optimal alignment (heels vertical) so weight bearing

is through the center of the foot

Fig. 6.1—Gait cycle of one-year-old. Used with permission from: D.H. Sutherland, R. A. Olshen, E.N. Biden, and M.P. Wyatt, Clinics in Developmental Medicine No. 104/105: The Development of Mature Walking (London, England: Mac Keith Press, 1988), p. 129.

FS=foot-strike TO=toe-off OFS=opposite foot-strike OTO=opposite toe-off

Gross Motor Skills for Children with Down Syndrome ! 293

4. weight shifting from the heel to the ball of the foot, progressing to toe push-off when stepping

5. trunk leaning forward and pelvis rotating on the trunk6. longer step length7. knees unlocked and moving smoothly between bending and

straightening8. hip hyperextension (side view: thigh moving behind the hip

joint; see circled area, fig. 6.2) in combination with toe push-off for propulsion and efficiency

9. legs in vertical alignment without tilting at knees or ankles10. arms at sides and reciprocal arm swing11. increased speed and endurance

Fig. 6.2—Gait cycle of two-and-a-half-year-old. Used with permission from: D.H. Sutherland, R. A. Olshen, E.N. Biden, and M.P. Wyatt, Clinics in Developmental Medi-cine No. 104/105: The Development of Mature Walking (London, England: Mac Keith Press, 1988), p. 135.

FS=foot-strike TO=toe-off OFS=opposite foot-strike OTO=opposite toe-off


Post Walking SkillsThese new components for the refined walking pattern will be devel-

oped through practicing the following post walking skills and using proper foot support. (Foot support will be discussed on pages 299-311.) The post walking skills are:

1. walking on uneven surfaces, and around or over obstacles 2. fast stepping and running3. walking up and down inclined surfaces4. kicking a ball5. walking up and down curbs6. walking up and down stairs7. jumping8. pedaling and steering a tricycle9. walking across a balance beam

These skills were selected because they contribute specific movements to improve walking, and they are also necessary skills for independence in the community and at school, and for playtime with siblings and peers. In the beginning, the most important skill to focus on is fast stepping and running. In chapters 7 to 15, the components of each of these skills will be discussed in detail so you understand the specific movements to focus on and how they improve walking. By practicing these skills, your child will gain strength in his trunk, legs, and feet, and his balance, speed, coordination, and endurance will improve.

In this period, you will have a new set of questions: ! My child walks with his feet wide apart; when will he walk

with his feet closer together like other kids? ! He wants to run and tries to go fast, but when will he learn to

run really fast rather than use a jogging pace? ! He prefers to climb up and down the stairs rather than walk;

when will he safely walk up and down the flight of stairs by himself?

! He says “jump,” and he wants to jump, but he can’t get both of his feet off the ground simultaneously. When will he learn to jump?

Your child can learn to do all of these skills with proficiency, and the fol-lowing chapters will teach you the strategies to use. The ages for these skills are approximately 2 to 6 years. Your child will be ready to start practicing these skills when he can walk in the house all of the time, is motivated to walk, and is confident and competent with walking on level surfaces.


How you practice gross motor skills in the Post Walking period of devel-opment will be different from how you practiced skills in the Birth to Walking period. In the birth to walking period, you focused on the skills of the stage the child was in, and he achieved the goals of each stage within a few months. In the post walking period, you will introduce all of the skills and practice what he is interested in at any given time. So he will be working on learning many skills at the same time. I advise you to read all of the post walking chap-ters, focusing on his level in learning each skill.

It will take awhile for him to achieve the goals in each skill area, and in the meantime, he will be working on each step in the process toward the goal. By focusing on the steps toward the goal, you will be able to measure his progress in that skill. You will appreciate his progress by looking at the improvements in the components that he uses, refinements in executing the skill, and the subtle changes that ultimately will result in achieving the goal. For some skills, such as curbs, stairs, and the tricycle, he will need to grow. For other skills, such as learning to generate lift-off for jumping, he will need to be confident and adventuresome. According to the data I have collected, the average ages to achieve the gross motor goals of the post walking period are:

Average ages to achieve the gross motor goals of the post walking period:

Walk down a 4-inch (10-cm) curb, without support

Walk up a 4-inch (10-cm) curb, without support

Fast step 100 feet (30 meters) in 25 seconds

Walk across 7.5-inch (19-cm) wide balance beam

Walk up stairs, two feet per stair, with one hand holding the rail

Walk down stairs, two feet per stair, with one hand holding the rail

Jump on floor with both feet together

Walk down 8-inch (20-cm) curb, without support

Walk up 8-inch (20-cm) curb, without support

Run 100 feet (30 meters) in 15 seconds

Walk up stairs, one foot per stair, with one hand holding the rail

Pedal tricycle 15 feet (4.5 meters)

35 months

36 months

37 months

38 months

39 months

40 months

47 months

47 months

49 months

52 months

56 months

61 months

The following skills have a wide range of variability:

Walk across 4.5-inch (11-cm) wide balance beam

Walk down stairs, one foot per stair, with one hand holding the rail

64 months

6-8 years


Factors That Affect the Development of Post Walking Skills

A number of factors will influence your child’s ability to master the nine skill areas of the Post Walking period of development. These factors fall into four categories:

1. Physical problems: including hypotonia, decreased strength, increased joint flexibility due to lax ligaments, short arms and legs, and difficulty with balance;

2. Temperament;3. Attention;4. Readiness and motivation to do a skill.

Physical ProblemsThe physical problems observed in children with Down syndrome are

covered at the beginning of the book on pages xii-xv. Now that your child is older, his hypotonia has decreased and you probably will not notice it when he is doing an established skill that he executes efficiently. However, when he is learning a new skill such as running or jumping, you will notice it in the area of coordination. You will also notice it in his abdomen when he stands still in a relaxed position. When he is at rest, his abdomen may protrude due to hypotonia. However, if you watch his abdomen when he is active, you will see that he has strong abdominal muscles when he activates them.

Your child’s strength will improve with repetition and practice. The key is to find the activities that he likes to do, and then he will naturally do them often and for long periods. As he practices, watch his movements and help him do the skills properly so he develops strength in the right muscles, and in the optimal way.

Increased joint flexibility will be present and the primary areas to focus on are his feet, knees, and neck. Your child will have his own unique degree of laxity. The goal is to be proactive to protect his joints so he does not stretch his ligaments further. He may have ligamentous laxity in his ankles and knees, and need foot support to walk with a refined pattern and for im-proved gross motor skill performance. The next section of this chapter will address foot management. Also watch his sitting posture on the floor. If he makes a habit of w-sitting, encourage him to sit instead on a child’s chair or a bench (90/90 sitting), or to sit with legs crossed (criss-cross position). When a child uses the w-sit position, he excessively stretches the medial knee liga-ments and this adds to the knee tilt (valgus) when standing and walking.

People with Down syndrome are also at risk for atlantoaxial instability, due to ligamentous laxity at the first two bones of the neck. In this condition,


one of the topmost vertebrae in the neck slips forward on the next vertebra and compresses the spinal cord. (See page 313.)

The length of your child’s arms and legs will be short relative to the length of his trunk. This will affect the following skills: walking up and down stairs and curbs and pedaling a tricycle. Sometimes you will need to wait for his legs to grow before he can achieve the next goal in these skill areas.

Children with Down syndrome have difficulty with balance skills and need practice to gain competence in this area. They may need foot support to be successful (see “Foot Management,” below). They also need to be mo-tivated to persevere with practicing it, so the setup needs to be fun for them. For example, a child may not want to stand on one foot for several seconds in the clinic setting, but he may want to do the tree pose in yoga class or the passé pose in dance class. He will also learn balance by practicing skills such as kicking a ball, walking up and down curbs (without hand support), and walking across a balance beam (without hand support).

TemperamentWhether your child is motor driven or an observer, he will be active

during the Post Walking period of development. It is still important to ob-serve which temperament your child tends to have as he learns each new skill and be sensitive to his learning style in your approach to teaching the post walking skills.

If he is motor driven, he will prefer vigorous gross motor activities such as running, climbing, walking up and down inclined surfaces, kicking the ball, and jumping. When practicing skills, he will enjoy it if you move fast. He will not want to move slowly and pay attention, for example with balance beam skills. He will tend to be risky and do activities without paying atten-tion to how to do them safely. He will need to be supervised closely to see what he is up to and to make sure he is safe. As he practices the skills, he will learn how to do them safely, and he will learn to pay attention.

If your child is an observer, he will pay attention to each skill and try to do it with control. He will like walking on a balance beam and walking up and down stairs with support. He will tolerate practicing all of the post walking skills with support, so he can learn how to do each skill. Once he is comfortable with doing the skill, he will do it on his own. He will enjoy running fast with support and will need encouragement to learn to run fast on his own. He will tend to be careful, so will feel safer practicing skills that he knows how to do.

AttentionCertain post walking skills will require your child to move slower

and pay attention. When your child walks on uneven surfaces, around ob-


stacles, and from one surface to another, he will need to look down at the ground to plan how he can walk and avoid falling. When he walks across the balance beam, he will need to watch his feet and step within the boundary. When walking up and down a 2-inch (5-cm) curb, he will need to be aware of it and plan how to step up and down with control. By prac-ticing these skills, he will learn to slow down and pay attention to what he is doing so he can be successful.

If your child is an observer, he will pay attention to the details of what he sees and feels, and will react with a plan of how to move safely. If your child is motor driven, he will tend to take the trial-and-error approach and react in the moment. If you give verbal and visual cues to elicit his attention, then he will begin to notice the details that he needs to attend to for each skill. He will learn to pay attention by practicing the skills that require it.

When needed, help your child focus his attention by giving visual, ver-bal, or tactile cues. Set the equipment up in such a way that he sees different surfaces, or he watches a sibling model the skill so he can imitate how his sibling did it. Give him verbal cues like “up” and “down” so he notices that he needs to step up and down the mat surface. He will experience the tactile cues as he practices the skill. For example, if you practice balance beam skills by walking across a 7.5-inch (19-cm) wide piece of wood placed on the floor, your child will notice when he steps out of the boundary. This setup will get his attention better than walking between two pieces of tape or a painted stripe on the floor. With each skill, there are ways to help your child pay at-tention in order to learn how to do it. You will learn to be creative in finding ways to help him focus his attention.

Readiness and Motivation to Do the SkillLet your child choose the skills he wants to practice since he will natu-

rally show you what he is motivated to do. If he likes a skill, he will auto-matically challenge himself to the next level, and he will initiate practicing it for many repetitions. To broaden what he chooses to practice, encourage siblings and peers to practice certain skills with him. If he sees that they like to do the skill, then he will want to do it with them. Practicing with his sib-lings and peers will give him models to imitate but even more importantly, he will be motivated to do the skill because they are doing it. If your child is not showing an interest in a particular skill, practice it briefly in a fun way to keep it familiar while you wait for him to show the desire to do it. When he is ready and motivated to do a skill, he will figure out what he needs to do to be successful.


Foot ManagementWhat Causes Flat Feet in Children with Down Syndrome?

As discussed in Chapter 4, children with Down syndrome are at risk for foot alignment problems, primarily due to ligamentous laxity. The ligaments that hold the bones of the feet together have more stretch, so they do not hold the bones together tightly for optimal alignment and function. The joints of the foot have excessive flexibility, which causes instability and inefficient me-chanics when standing and walking, and doing post walking skills.

The foot has 26 bones and can be divided into 3 sections: the hindfoot (the heel bone and the talus, which sits on top of the heel bone), the mid-foot (5 small bones in close contact with the bones of the hindfoot), and the forefoot (5 long bones of the foot, and the 14 bones of the toes). In children with Down syndrome, ligamentous laxity can cause the following alignment problems in these areas of the foot:

1. Hindfoot: The top of the heel bone tilts inward (rather than be-ing held vertically), which causes the talus to slide downward and toward the inside border of the foot, resulting in a flat arch. (See figs. 6.4-6.5.) You can observe this heel tilt by standing behind your child and watching his heels as he stands and walks barefoot.

(fig. 6.3) Optimal alignment, heel vertical

(fig. 6.4) Heel tilt (fig. 6.5)

2. Midfoot: Depending on the degree of laxity, the bones of the midfoot may be pulled inward by the sloping talus, and then the arch is flattened further. (See figs. 6.7-6.8.) You can observe the flatness of the arch and the length of the flatness by looking at your child’s arch from the side view.

(fig. 6.8)


3. Forefoot: After you have observed your child’s hindfoot and midfoot, stand in front of him and observe whether his feet point straight ahead or turn outward (called toeing-out). With the heel tilt and the collapse and stretch of the medial arch, the long bones of the foot and the toes may turn outward. (See figs. 6.10-6.11.)

left (fig. 6.9) Optimal alignment, foot pointing straight; center (fig 6.10); right (fig. 6.11) Toeing out

(fig. 6.6) Optimal alignment with arch (fig. 6.7) Flat arch

4. If the heel tilts and the entire inside border of the foot is col-lapsed, you may also see that the big toe turns and bends (toward the second toe) or tilts sideways toward the second toe (fig. 6.12).

5. If your child has toeing-out (3 and/or 4) as described above, he will also have excessive weight bearing on the ball of his big toe. Eventually, this can cause callous formation, and walking can be painful, especially when he is older and bigger.

6. In some children, you see the opposite position of the big toe. The big toe tilts inward, and it is caused by an overactive mus-cle, the abductor hallucis longus (fig. 6.13). The degree of the toeing-in may just involve the big toe, or it may cause the fore-foot to turn inward.


Why Is Flat Footedness a Problem?If your child has any of the alignment problems described above, there

will be functional consequences in all gross motor skills involving standing. Not only does it affect the foot and ankle movements, but also the move-ments of the joints above—in particular, the knees and hips. The individual joint movements do not occur properly, and then you have the added effect of several joints moving improperly. A simple comparison is to see how a door swings on its hinges. It glides when it is working properly but scrapes, im-pinges, and stops moving when it is not hung right, and it takes more power to move. If your child has faulty foot alignment, he cannot use his strength effectively because the muscles are not aligned for efficient activation. Since his strength does not generate efficient power, he uses more energy to do the skill and fatigues more quickly.

Since walking is vital for your child’s mobility for his entire lifetime, it is very important to be proactive in promoting optimal alignment and function, beginning when he learns to walk. The consequences of faulty mechanics range from impaired performance to pain, which can result in limitations in walking.

Examples of common alignment problems and their consequences are:1. If your child’s heels tilt an he has flat

arches and walks bearing weight on the inside borders of his feet, he will walk with a wider base, with his heels wider than his hips. If you look at his knees, they will probably tilt inward. When you look at his legs and feet, they will not be in the optimal vertical alignment but instead will have vary-ing degrees of tilting at each joint (fig. 6.14). When he walks and runs using toe push-off, he will take excessive

(fig. 6.13) Used with permission from: Blandine Calais-Germain, Anatomy of Movement (Seattle, WA: Eastland Press, 2007), 284.

(fig. 6.12)

(fig. 6.14)


weight on the inside borders of his feet, especially under the ball of his big toe. This area will take a lot of impact and shearing forc-es and will probably develop a callous, and may become painful.

2. If your child walks with his hips in external rotation (thighs and knees turned outward), he will not be able to move his hips into hyperextension (see fig. 6.2), so he will walk and run with short-er steps. He will walk and run with hips and knees bent, like a jogging pattern. If he cannot move his hips into hyperextension, he will not be able to use toe push-off for efficient propulsion. (In order to move the hip into hyperextension, the hip needs to be in neutral rotation.)

3. If he uses the walking and running patterns described above, he will learn to do these skills using faulty mechanics, and will not learn to do them efficiently or progress to his optimal performance level. As his growth increases over time, his liga-ments will be further stretched in this pattern. The long-term effect will be muscle tightness, and his feet will become rigid in the position. However, if you provide foot support, his feet will remain flexible enough to accommodate the support and he will have flexible flat feet (that can be supported in the optimal posi-tion) rather than rigid flat feet.

What Can Be Done?Your child will need to be evaluated to see if foot support is needed. If

it is needed, then it is important to determine when the best time is to start using foot support. The vast majority of children with Down syndrome will need support to provide stability. Some children begin using foot support when they are learning to walk with support, and others use foot support after walking is mastered, in order to refine their walking pattern. The goal is to provide the right support for two purposes: 1) optimal alignment of the legs and feet, and 2) improved function. Your child needs to be able to use the support dynamically for efficient walking and running, so he can walk and run with speed for long distances.

The best time to first evaluate whether your child needs foot support is after he pulls to stand (from sitting on the floor) by himself and is motivated to play in standing (Stage 4). When he can pull to stand, he is ready to prac-tice cruising and stepping with your assistance (Stage 5). The foot support is only beneficial when he is in standing, so the best time to begin using it (if needed) is when he is at this skill level. Therefore, when a child pulls to stand and wants to stand much of the time, I evaluate his standing posture to deter-mine whether foot support is needed. (See box on pages 184-85.)


If your child did not need foot support when first evaluated, then contin-ue to watch his foot posture as he spends more time in standing and practicing stepping with support. When he practices walking with support several times daily for long distances, his foot posture may change and foot support may be needed. If he does not need foot support when he is learning to walk, then evaluate his feet after he is walking independently, all of the time. At this time, evaluate whether foot support is needed to refine his walking pattern.

To evaluate your child’s foot posture to determine whether he needs foot support, you need the best setup. Watch his feet while he is walking bare-footed to observe his best performance and the variations he tends to use.

Here are recommended guidelines to follow:1. Have him walk quickly and directly to a specific endpoint about

30-50 feet away. If possible, use a long hallway so he is not dis-tracted. He needs to walk a long distance so he is motivated to use an efficient pattern. If he walks slowly, turns his head to look at something, deviates to the right or left, or is distracted, you will see changes in his foot posture. Practice in this space for several repetitions to observe his best performance.

2. Observe his walking pattern from these 3 views:A. Standing behind him:

! Look at the width of his base by observing how close together his heels are. See if he walks with a wide base (heels wider than hips) or a narrow base (heels in line with his hips).

! Look at his heels and see if they are vertical or if they tilt while he is walking. Watch one foot at a time if you need to so you can really study how it moves as he walks the long distance.

! Look at his knees and see if his thighs and lower legs are vertical or if his knees tilt inward.

B. Standing in front of him: ! Watch his feet and see if they point straight ahead or

if they turn outward. ! Observe his knees to see if they tilt inward or if his

legs are straight.C. Standing at his side, on the right and on the left

! Look at the arch area of each foot and see if it is flat or if he activates his muscles to lift the arch a little.

3. The optimal walking posture is with a narrow base, his knees and heels vertical, and his feet pointing straight ahead.


4. If he does tilt the top of his heel bones inward, has flat arches, and his feet turn out, check the flexibility in his feet while he is standing. (His feet will need to be flexible to accommodate the support.) Sit on the floor in front of him and position his heels in line with his hips (narrow base) with his feet pointing straight. If needed, place your feet on the outsides of his feet to maintain them in this position. Then hold his heels and move them to the vertical position and see if you can move his feet so he has a lift-ed arch. If he does not tolerate the heel support, then cross your hands (palms up) and use your fingertips to lift his arches. Feel if he has the foot mobility to be supported in this position. When you are moving his feet to test the flexibility, let him hold onto a support if he feels unstable.

5. Do not evaluate his foot posture when standing and playing because he will automatically use a wider base and turn his feet out for stability. With a wider base and toeing-out, his heels will tilt and his arches will naturally be flat.

What Types of Foot Support Are Recommended?If your child needs foot support, a variety of types are available depend-

ing on his age, needs, size and weight, and what he will tolerate. His leg and foot posture will need to be evaluated along with his activity preferences and motor performance. What is needed for a 3-year-old is different than what is needed for a 13-year-old. The foot support will be a tool to improve his walk-ing posture and gross motor skill performance. The goal of the foot support is to improve his function by providing support for optimal alignment so he can use his strength, balance, and coordination more efficiently. By improving his function, he will be motivated to be active, his endurance will increase, and his overall activity level will increase.

The type of support for each child needs to be determined on a case-by-case basis, and depends on the factors listed above. A critical factor is whether your child will tolerate the support, because it will not help him if he will not wear it. To determine the type of support needed, it is best to have a team approach, and the team needs to be experienced with the best types of foot support for children with Down syndrome and the goal of the support. The team can include the PT, orthotist, parents, pediatrician, and orthopedist. The recommended foot support will need to be tested for effectiveness and modified until the desired results are achieved.

In my experience, children with Down syndrome generally tolerate flex-ible supports better than rigid supports. Rigid supports tend to reduce the foot’s ability to move naturally through the gait cycle. Many types of support are

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