Please welcome pediatric occupational therapist Corey Webb Stone, as she shares about how to teach shoe tying to kids who have difficulty using one arm or hand.
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Tying your shoes can be a difficult thing to learn as a small child, especially if you are only working with one functional hand. In our clinic, a Constraint-induced Movement Therapy clinic (find a further explanation of CIMT here), we see children with various neuromotor disorders (when the brain has difficulty communicating with the muscles). These children have the common underlying theme of presenting with one functional arm/hand (referred to here as the “uninvolved” side), and one that requires more time and effort to use (referred to here as the “involved” side).
One of the biggest goals of our school-aged clients is learning the skill of tying their shoes. During the weeks where their uninvolved side is casted in order to promote use of the involved side, we primarily focus on using the involved hand with some spurts of bilateral (two-handed) time dependent upon the child’s tolerance and goals. During the unilateral (one-handed/casted) days we, as therapists, act as their other hand in the process of learning to tie shoes. The child assists us in completing the activity with their involved side. We see lots of success once the bilateral week arrives (when they get to use both hands again), because the child has already mastered the skill unilaterally with their involved side. All that is left is learning to incorporate the two hands together!
While each child is different, we find that most of our clients learn best when they master an understanding of the process of shoe tying first. Our starting point with each child is having them master the ability to verbally walk themselves and the therapist through the steps of tying shoes. Once they learn the process we begin to work on physically mastering one step at a time.
For most children the last few steps are the most difficult and are essentially where most of the time is spent. For some children, a process called Backward Chaining (teaching/mastering the steps in reverse order) works best, or a combo of both backwards and forwards chaining. During treatment we focus on massed practice (repetition even after mastering skill) of the step that is hardest for the child by either having focused time on that particular step, or sandwiching small increments of attempts (i.e. 3 successful attempts) in between more fun activities.
Most of the shoe-tying sequences we teach are modified specifically for each child dependent upon his or her level of function in the involved hand. If the child is able to fully open his or her hand and isolate a pincer grasp (pinching with pointer and thumb), then we encourage full use of the hand in the process. A lot of children have difficulty with pulling the loop through in the last few steps, as well as holding the loop steady for the other string to wrap around. In those instances, we encourage the child to use the involved side as a stabilizing point for the uninvolved side to complete the job. This way both hands are still working together to complete the task and the involved side is still receiving input.
Here are some pictures and step-by-step instructions of one sequence we have used to successfully teach shoe tying to children with motor difficulties:
Step 1: Pinch strings with both hands.
Step 2: Make an X.
Step 3: String on top goes through hole made by the X.
Step 4: Repeat Step 3. Lace will be looped around twice. Pull tight. (Looping through twice helps keep the knot from loosening.)
Steps 5 and 6: Involved hand holds side of shoe. Uninvolved hand threads lace under knot to make loop.
Step 7: Uninvolved hand circles loop with opposite lace.
Step 8: While holding onto first loop, push second loop through with fingers.
Steps 9 and 10: Slowly transition hands to grab onto both loops and pull tight. (This step needs to be taken very slowly as to not accidentally pull strings too far.)
Please feel free to leave a comment below if you have questions about any of these steps or the way we teach shoe tying to children with motor difficulties.
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Corey Webb Stone is a pediatric occupational therapist at the UAB Pediatric Neuromotor Clinic, Intensive Occupational Therapy: an ACQUIREc Therapy Model, located in Birmingham, Alabama. Corey received her Bachelor of Science Degree in Rehabilitation Services from Auburn University and her Master of Science in Occupational Therapy from the University of Alabama at Birmingham. She has a wide range of experience in working with individuals with disabilities, and currently specializes in pediatric constraint-induced movement therapy for children with neuromotor disorders. An Alabama native, Corey currently lives in a small town outside of Birmingham with her handsome husband, two energetic Chihuahuas, loyal beagle, and fluffy cat.
For more information about the UAB Pediatric Neuromotor Clinic visit http://www.uab.edu/civitansparks/pediatric-neuromotor, or find us on Facebook at https://www.facebook.com/UABPediatricNeuromotorClinic.