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W sitting position

Discussion in 'Pediatrics' started by posalafin, Jan 1, 2010.

  1. posalafin

    posalafin Active Member


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    Seeking advice.

    3.5yo female, born at term by normal vaginal delivery, no neonatal complications. Has reached all developmetal milestones at age appropriate rate. No illnesses or regular medications, has recieved all recommended immunisations. No significant materanal Hx generally, but mother does have bilateral HAV. Physically very active & has never complained of any foot pain or discomfort.

    For past 18 months has been regularly sitting in W position and when she sits in this position she frequently rocks backwards & forwards. Parents try hard to stop her sitting this way and encourage her constantly to sit with legs out in front or to the side. Recently she has developed bruising & blistering to the medial aspect of the dorsum of both feet from the sitting position & rocking. The issue has been brought up on visits to to the GP and paediatrician as the parents were concerned that she may be autistic (purely based on the sitting & rocking) however this has been discarded by both the GP and paediatrician.

    I observed her sitting in the W position & rocking however she seems to rock backwards & forwards intemittently i.e. she will rock for a few seconds then stop for up to a couple of minutes then rock again for a few seconds. When I would get her to sit with her legs out in front she would plantarflex & evert both feet (almost like a decerebrate posturing). When I got her to watch a "Wiggles" video she initially sat in W position doing the intermittent rocking. I then got her to sit with her legs out in front while she was watching the video which she was very absorbed in. When sitting with legs in front she would intermittently arch her back and her feet would plantarflex & invert (decerebrate like posturing again) like when I first got her to straighten her legs. This posturing would only last a few seconds then she would relax but it recurred every 30seconds or so while she was sitting straight legged. When I got her to sit in a chair with her legs out in front I didn't notice any of the posturing but she wouldn't sit in the chair for long and would sit back on the floor in the W position.

    All her muscles groups have good strength, ankle & patellar reflexes appeared normal (however she was a bit unco-operative with this test),gastrocs are a bit tight, rearfoot valgus, pronates throughout gait, although her parents said this has improved significantly in past 6 months. Has MLA in heel raises & 'Jack's test'. Wears good quality, supportive shoes. Psychologically her parents say she is a bit 'shyer' than most of her peers but otherwise interacts well with her peers & adults.

    Can anybody provide any advice on children sitting in the W position in terms of pathological processes that might be causing this or is it more likely psychological and to be something she will 'grow out of'. My feeling is that there may be a neurological cause due to the posturing she displays but would be keen to hear from anybody with experience / knowledge in this area.

    Regards,

    David Kelly
     
  2. David:

    I don't think I would be very concerned with a 3.5 year old child that liked to sit in a "W" position, since I see this frequently in children that have more internal hip rotation than normal (children with more external hip rotation seem to prefer "Indiian style" or cross-legged sitting). If her gait is relatively normal in walking and running, she is active, happy and having no other problems, then my advice is to let the girl be a girl and don't worry about how she sits. I would also probably advise the parents to save their worries for something that has more medical significance.
     
  3. Craig Payne

    Craig Payne Moderator

    Articles:
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    Chicken and egg! Does sitting that way cause the higher internal rotation ROM at the hip or do they site that way because its more comfortable for them, as they already have a high internal ROM at the hip?
     
  4. Bug

    Bug Well-Known Member

    I would worry too much about if there is normal hip rom. In the light of medical professionals discounting autism and if speech. gross motor etc is all OK then I would think perhaps bad habit, self stimulation/gratification or you could go down the sensory path with vestibular stimulation.

    I find that w sitters have poorer balance than their peers however most are still in a normal range. The position lets them play on the floor with a more stable base.

    I'd encourage the parent to change floor play to chair and table and beanbag for tv and then not to worry too much about it. She will get to kinder and peer pressure of kinder sitting should come into play.
     
  5. Adrian Misseri

    Adrian Misseri Active Member

    G'day David,

    I agree with the other guys here in that she is happy and healthy and keeping up with the other kids, I'd just continue to watch and monitor her. It sounds to me like a learned behavior, she probably enjoys it and has created a mental link between fun things (like sitting and playing, and watching the Wiggles), with sitting in that position and rocking, and teh movements associated with it. Bear in mind also that at ages from about 2 on to 5 or so the hips are developmentally internally rotated, and will not 'unwind' untill 7 or 8.

    Cheers!
     
  6. posalafin

    posalafin Active Member

    Thanks for your replies and advice.

    Regards,

    David Kelly
     
  7. RobinP

    RobinP Well-Known Member

    Hi there, before I start this post, I want to make it clear that I am no expert and that most of what I am about to say is probably a poor regurgitation of things I was told by the physiotherapist Beverley Cusick when talking about W sitting.

    I am going to swim against the tide of opinion here and say that I think that W sitting is one of the cardinal sins! I agree with Craig's question in that we don't know if there is a predisposition to internal rotation at the hip that makes W sitting more comfortable/stable for the child or whether the W sitting has caused internal rotation and, like plagiocephaly of the head, once the bony moulding has taken place, the natural posturing will compound the existing deformity.

    I can understand why children choose to W sit when younger. I am sure that a combination of W sitting probably requiring less muscular involvement, having a wider base of support and allowing closer access to toys when playing all contribute to its popularity.

    However, by the age of 7, osseous structures have lost their plasticity, and remoulding cannot take place so readily. Over a prolonged period of time, W sitting will cause femoral anteversion. Left past the age of 7 or 8, the anteversion will not change until the age of 14-16 and inevitably, the child will be stuck with an intoeing gait unless compensatory external rotation has taken place elsewhere. I therefore think that letting the child continue to W sit is creating a problem that need not exist.

    Although the intoeing will probably reduce by 4 or 5 degrees as the child goes through adolescence, if starting from a very anteverted alignment, the correction may not be back to "normal". However, there is probably an element of social factors that encourage muscular retraining in order to mask the intoeing at the adolescent age.

    If you want to assess the effect of the W sitting on femoral enteversion, you may be interested in this paper by Beverly Cusick which shows transverse plane assessment techniques for the lower limb. It is with reference to neuromuscular disorders but the tests can be quite interesting especially when assessing the degree of external tibial torsion as a compensation for femoral anteversion.

    http://ptjournal.apta.org/cgi/reprint/72/1/3.pdf



    So that is my feeling on W sitting. With reference to your problem David, the factors you describe of frequent muscular "patterns" and tight gastrocs would also make me think of a neurological disorder. At 3.5 y/o, it is pretty hard to diagnose and even MRIs are inconsistent and not truly diagnostic.

    Try doing a Fogg test. It is not a well documented test for the simple reason that it is not diagnostic. However, it can be a good indicator of a neurological anomalie. The test is to get the child to walk on the lateral borders of their feet. They may or may not be able to do it. However, the act of trying will stress the CNS and you may, if there is a suggestion of neurological damage, see some upper limb activity. The normal pattern for a +ve test is for the wrists to flex and the elbows to flex and for the arms to go out to the side. If the child seems to be struggling to do this, ask them to walk around on their toes and look for involuntary upper limb movements. See this article by Devlin. page 131

    http://apt.rcpsych.org/cgi/reprint/9/2/125

    If there is a +ve result, then neurological investigation may be worthwhile. But then ask yourself, will it make any difference to how the child will develop if it so mild as to not yet have been picked up? In many cases, the answer is no, so doing the investigation only gives the opportunity to label the child which may not always be of benefit to the child or the child's family

    I hope that you find this helpful and as I said, I am no expert and most certainly not infallible so maybe my ramblings will lead you to discover your own truths.
     
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