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There are no words which generate greater guilt in new parents than when a health professional asks, ‘Have you been doing Tummy Time?!’ Despite knowing the benefits because infants protest so loudly parents often do just enough (speaking from experience here), to reduce their guilt until this awkward stage can be forgotten. However, for parents of a child with a disability/delay this position is more critical and unfortunately likely to last way longer. So, what can therapists do to help?
Well, knowledge is power and as we know getting buy-in from family is key, so begin with some education describing how babies begin life in physiological flexion - spine and head flexed, knees and elbows tucked in. Active tone develops at around 36 weeks in utero causing an increase in extensor muscle tone which helps develop an upright posture.
For children with an illness, disability, special needs or developmental delay, progression through this stage, where extension vies to balance flexion, takes more time and is harder to achieve, risking further delay. Prone activities play a crucial role in supporting physiological and cognitive functions. A chat about the numerous benefits can be persuasive:
Strength – prone is the key position to develop strength in the hands, arms, shoulder girdle and the all-important anti-gravity muscles of the neck and back. Postural control develops cranio-caudally, and the muscles used in prone positioning are relied on for function such as classroom activities (think looking up and down at the board), feeding and personal care.
Range of Movement – prone positioning provides a deep long stretch to the hip flexors and abdominals. These muscles are often tight, short or both, either from residual physiological flexion or from long periods sitting. It can also help prevent or correct a torticollis
Sensory processing –the list here is virtually endless. Visual processing, oculomotor development and depth perception all benefit from the new position. Anterior weight-bearing will increase proprioception and body awareness. This deep pressure can be calming for some children if they feel stable and emotionally secure (not just abandoned on the floor). Prone movements stimulate the vestibular system, helping to develop the understanding between head orientation and gravity.
Plagiocephaly – since the back to sleep campaign the incidence of plagiocephaly has increased dramatically from 2% to recent reports of over 40% with car seats and other equipment increasing the time supine. Frequent bursts of prone positioning reduce chance of plagiocephaly.
Neuromuscular control: Mapping the sensory systems to muscle activation promotes cognitive development and increases neuromuscular control. While head control begins in supine, lifting the head in prone is one of the key components to developing head control (link to assessment guide poster). This movement is an important precursor to propping on elbows, then on hands, balancing on just one hand, weight shifting between hands and learning to pivot on the spot to grasp a toy out of reach.
And of course, it is worth reminding parents that prone skills influence subsequent motor milestones such as rolling, crawling, sitting, standing and walking.
Which exercises for which child?
Interventions should be child initiated, task-specific and personalised to suit the child’s enjoyment. Why? Because these types of interventions are the ones that induce neuroplasticity and produce functional gains (Novak, 2017).
In early months – aim for lots of skin contact with no equipment
- Tummy to tummy – adult semi-reclined on sofa with baby on top (basically a cuddle!)
- Infant held in adult arm with their head in the crook of the elbow to let them look about (you need good strength for this one)
- Playing airplane with parent on their back, supporting the child on their legs
As head lift develops – prop up on elbows, then on hands
- Over your lap with one knee higher than the other, elbows under shoulders. Prone should not cause discomfort. This position can work well for tube fed children who can be placed in prone 2-4 weeks after the operation (seek paediatrician advice). If possible, disconnect tubing and close the button.
- Chest-to chest with adult on the floor and baby propped on elbows then hands. Peek-a-boo stimulates neck flexion and extension
- Hypotonia requires more effort to oppose gravity. Using a ramp or wedge will decrease the effort required. The higher the ramp the easier it becomes. Gentle pressure on the bottom will provide stability and encourage push through the arms.
As propping is mastered encourage single arm support and weight shift
- Start by gentle rocking side-to-side to experience increased weight and balance shift.
- Hypertonia makes controlling movement more difficult to achieve. If child habitually adopts extended postures try to break the pattern with a chunky roll under the tummy with hips, knees and ankles held flexed under the bottom
- A new toy or even a chocolate button may help them let go and reach
- Vary the toy, the position, the playmate. Other kids are great helpers here
At developmentally equivalent stage bring in equipment
- Gentle rolling on large ball (try that one which was never used during pregnancy/childbirth)
- Short periods in a prone stander with high tray. For hypertonia with habitual flexion, equipment can ensure proper alignment.
- Visual impairment necessitates creative strategies to engage and motivate. Use the other senses to provide distraction, such as a cloth infused with essential oils. Toys that crunch, chime, clang and rustle will spark curiosity.
- Lower limb activity in a well-supported, walker will stimulate upper body extension – start with very short sessions
Prone is a demanding position. The child must work against gravity. Making it child centred means adapting the posture, environment, and expectations to suit the child. If parents can remember awake, alert and active then they’re going to have a positive impact on development.
Lastly with this as in everything, variety is the spice of life.
Novak I, Morgan C, Adde L, et al. Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment. JAMA Pediatr. 2017;171(9):897–907. doi:10.1001/jamapediatrics.2017.1689
https://www.nice.org.uk/guidance/cg145/chapter/1-Guidance#physical-therapy-physiotherapy-andor-occupational-therapy Published: July 2012 Last updated: November 2016
Saavedra SL, van Donkelaar P, Woollacott MH. Learning about gravity: segmental assessment of upright control as infants develop independent sitting. J Neurophysiol.2012; 108:2215-2229.
