Know the Signs: 12+ months
12+ months: Rise to stand
Greater than 12 months: Rise to stand from floor
Description
Watch for independent rise from floor from a supine position after child is able to walk well without assistance (generally 12-16 months); watch to see if child uses a Gower’s maneuver (full or modified, by putting hands even briefly on knees or thighs) or cannot rise without pulling up.
What do the effects of weakness in rise to stand look like?
Discussion
Repeat any time concerns are raised about walking or other motor function, to evaluate for regression.
Tip: An early Gower’s can be very subtle. Watch what it looks like.
Red Flag
A child who cannot rise from floor to stand without support (including without using hands on knees or thighs to push up) by 18 months, or who shows regression in rise to stand, needs further evaluation.
Therapist Response to Red Flag
Communicate specific concerns about rise from floor (in context of overall development and relevant environmental factors) to the family and referring provider. Provide evidence for weakness rather than poor coordination as a cause for the delay. Encourage a referral to a specialist (consider pediatric neurology) for a diagnostic evaluation.
Specialist Response to Red Flag
Draw a CK and refer for diagnostic workup.
Download a pdf of the Surveillance and Referral Aid for Therapists and Specialists. This Aid includes signs of weakness by age, red flags and warning signs for muscle weakness, and referral recommendations.
12+ months: Walking
Greater than 12 months: Walking
Description
Observe each step of child’s normal developmental progression to independent walking: pull up to stand, cruise holding on to furniture, stand alone, walk with one or both hands held, lower to sitting position from stand without falling; walk well.
What do the effects of weakness in gait look like?
Discussion
Look at quality of posture and gait, in reference to how long child has been walking.
Tip: Evaluate whether the child has problems walking when carrying an object the size of a small shoebox that is held at midline against the chest.
Yellow Flag
Pronation of feet and/or ankles when walking; mild lumbar lordosis/anterior pelvic tilt; increased width of base of support; lateral lean during stance (hip waddle); consistent toe walking
Red Flag
A child who does not walk well at 18 months, or shows regression in ability to walk, needs further evaluation.
Therapist Response to Red Flag
Communicate specific concerns about walking (in context of overall development and relevant environmental factors) to the family and referring provider. Provide evidence for weakness rather than poor coordination as a cause for the delay. Encourage a referral to a specialist (consider pediatric neurology) for a diagnostic evaluation.
Specialist Response to Red Flag
Draw a CK and refer for diagnostic workup.
Download a pdf of the Surveillance and Referral Aid for Therapists and Specialists. This Aid includes signs of weakness by age, red flags and warning signs for muscle weakness, and referral recommendations.
12+ months: Running
Greater than 12 months: Running
Description
Watch progression to run until running is achieved; watch for unusually frequent falls; ask about any concerns with walking, running, or frequent falls at all visits after milestone is achieved.
What do the effects of weakness in gait look like?
Discussion
A child who does not run at 20 months: monitor closely and communicate concerns to the family and referring provider. Particularly note the quality of running, especially if there are other motor concerns.
Tip: A true run means that both feet are off the floor simultaneously. If a child is attempting to run and is using a fast walk instead, his compensations will be exaggerated—e.g., he will pump/move arms for momentum and arch his back more, use a wider base of support, and will not be able to carry objects or drop objects while running.
Red Flag
A child who does not run at 24 months, or shows regression in ability to run, needs further evaluation.
Therapist Response to Red Flag
Communicate specific concerns about running (in context of overall development and relevant environmental factors) to the family and referring provider. Provide evidence for weakness rather than poor coordination as a cause for the delay. Encourage a referral to a specialist (consider pediatric neurology) for a diagnostic evaluation.
Specialist Response to Red Flag
Draw a CK and refer for diagnostic workup.
Download a pdf of the Surveillance and Referral Aid for Therapists and Specialists. This Aid includes signs of weakness by age, red flags and warning signs for muscle weakness, and referral recommendations.
12+ months: Climbing stairs
Greater than 12 months: Climbing stairs
Description
Evaluate stair climbing at 2 years and up
Discussion
Muscle weakness results in difficulty with stair climbing, which can be noted early. Children who are weak often avoid stairs. When going up stairs, they often crawl or stop to rest. Children who are weak use their arms excessively to pull themselves up the stair railing, and do not alternate feet (go step-over-step). Going down stairs, children who are weak also lead with one foot and usually have to hold onto the rail (but do not have as much difficulty as when going up).
Red Flag
Any child who uses the stair railing to pull him/herself hand-over-hand up stairs at any age (not just using rail for balance) needs further evaluation. Any child who cannot go up stairs alternating feet step-over-step by 3.5 years needs further evaluation.
Therapist Response to Red Flag
Evaluate in light of overall strength. Communicate specific concerns about stair climbing (in context of overall development and relevant environmental factors) the family and referring provider. Provide evidence for weakness rather than poor coordination as a cause for the delay. If weakness is suspected or identified, encourage a referral to a specialist (consider pediatric neurology) for a diagnostic evaluation.
Specialist Response to Red Flag
Evaluate in light of overall strength. Draw a CK. Refer for diagnostic workup if weakness is suspected or identified.
Download a pdf of the Surveillance and Referral Aid for Therapists and Specialists. This Aid includes signs of weakness by age, red flags and warning signs for muscle weakness, and referral recommendations.
Greater than 12 months: Jumping/Hopping
Description
Watch child jump (straight up) starting at about 2 years. Look to see that both feet clear the ground. Watch child hop on one foot starting at about 3.5 years.
What does jumping for a weak child look like?
Red Flag
Inability to jump with both feet simultaneously in the air by 2.5 years or inability to hop on one foot by 4 years requires further evaluation. Deterioration in these skills requires further evaluation.
Therapist Response to Red Flag
Evaluate in light of overall strength. Communicate specific concerns about jump and/or hop (in context of overall development and relevant environmental factors) to the family and referring provider. Provide evidence for weakness rather than poor coordination as a cause for the delay. Encourage a referral to a specialist (consider pediatric neurology) for a diagnostic evaluation
Specialist Response to Red Flag
Evaluate in light of overall strength. Refer for diagnostic workup if weakness is suspected or identified.
Download a pdf of the Surveillance and Referral Aid for Therapists and Specialists. This Aid includes signs of weakness by age, red flags and warning signs for muscle weakness, and referral recommendations.