Monday 26 March 2018

Proximal Stability before Distal Mobility .... What????

*** I am not a medical professional, all of the content in this post is based off of our own experiences. If you feel that your child would benefit from increasing their proximal stability, please consult a trusted medical professional. ****

I think it is truly amazing that no matter how far we are along our autism journey with O and L, we never stop learning. There is always a new facet of autism to learn about and last week was no different.

L has mentioned on numerous occasions over the last few weeks that the reason he doesn't want to go to school is because his hand starts to hurt when he has to do a lot of writing. We've also noticed at home, both recently and over the past few years, that he tires very easily when he is colouring or painting. In the past we've always put this down to L becoming bored of the activity but little did we know, it had more to do with his muscles tiring than with being bored.

When we mentioned this to his Occupational Therapist recently, she said it all had to do with L's proximal stability needing to be further developed before we could work on his distal mobility.

Huh??? I really must work on my stunned goldfish look!!

Prior to beginning our autism journey I had never heard of proximal stability or distal mobility.

So let's first talk about the first part of this statement - what is proximal stability?  Well, prepare to be enlightened!

Proximal stability refers to the chain of muscles that start at our core and go out towards our extremities. When we use the tiny muscles in our hand to complete fine motor tasks, we must first have a stable chain of muscles that run from our core muscles to our shoulder to our elbow, wrist and then to our fingers.

If that chain of muscles beginning at our core is not stable and strong, then it will be very difficult for us to hold a pen or pencil for a long period of time. Without good proximal stability, we also may have difficulty in maintaining an upright seated position when seated at a desk throughout the day.

And therein lies the issue for L. As his core is not as strong as it should be, the chain of muscles leading to his fingers are not as strong as they should be and hence his hand hurts when doing writing.

The second part of the statement, distal mobility, refers to the functions of our hands and our feet - or our fine motor control. To have good distal mobility we first need a strong chain of muscles or a strong proximal stability. 

In other words before we can have correct and effective function in our hands and feet, we need to work on strengthening the chain of muscles starting at the inside and working towards the outer muscles.

Proximal stability BEFORE distal mobility!

A simpler way to think about this concept is to think of it in terms of a baby learning to move around. Babies generally have a lot of mobility, L certainly did anyway, but not a lot of stability to begin with. A baby will develop their head and trunk control and strength long before they learn to sit up. A baby needs to develop their head and trunk control and strength in order for them to be able to sit up. Head and trunk control really are the building blocks for other physical movements for children.

Another way to think about this concept is when babies and toddlers are learning to draw or paint. When first learning to draw or paint, a child will use their entire arm to scribble or paint on paper or walls or furniture or whatever other medium that they are decorating. As the child's skills develop, they begin to rest their forearm on the table and then the movements are narrowed further to develop their fine motor control.

So it makes sense then that if a child is struggling to control a writing utensil or if they require constant assistance for other fine motor tasks, then they may lack the core stability or the stability along the chain of muscles required to do the fine motor task.

This concept makes a lot of sense for some of the things that O struggles with as well. O struggles to hold herself up when she wheelbarrow walks on her arms or when she tries to hang on the monkey bars. She lacks the strength along the chain of muscles to complete these tasks.

Both O and L tire easily when walking and riding their bikes or scooters. Again we always thought that they were simply running put of energy, but no, this also has to do with their proximal stability and the chain of muscles leading out from their core.

It is important to keep in mind that strengthening this chain of muscles from the core out takes time. At times it is important to shorten the chain and work on a small section at a time so that the child doesn't tire too quickly or become frustrated when they struggle with the task. If they are able to achieve a small task then the chances are that they'll more likely want to participate in future activities.

And as our Occupational Therapists have said on numerous occasions, they will often focus on the working on the building blocks before they work on the end goal for O and L.

If proximal stability and fine motor control were represented as a brick wall - proximal stability would be on one of the bottom rows of the wall and fine motor control would be towards the top of the wall. If the bottom row of the wall is not stable, the upper most rows will not be stable! There is no point in developing fine motor control if L is struggling to hold a pencil for a long period of time.

So how can we strengthen this chain of muscles or a child's proximal stability?

L and O love rolling over their peanut ball. I will put toys or other objects on the floor that they have to reach out to get from the peanut ball. The idea is that they have to lie on the peanut ball and use their hands to "walk" towards the objects. They then have to pick up an object and "walk" back on their hands to the start. This strengthens their core as well as their shoulder muscles.

We do a lot of activities and games with the little superheroes lying on their tummies as this helps to stimulate their core muscles and strengthen their shoulder muscles as they hold their head and shoulders up to complete the activity. We also encourage them to sit in different positions such as long legged sitting or on a wobble cushion as they play as this also assists in strengthening their core muscles.

During therapy sessions, L will stand or kneel to write or draw on the vertical whiteboards in the therapy rooms which assists in strengthening his shoulder muscles. Kneeling and standing stimulates different muscle groups along the chain running out from L's core and as such both actions help his muscles to become strong and stable.

We encourage O and L to climb on play equipment or trees when we visit our local parks as this helps to strengthen their core muscles and the chain of muscles out to their limbs.

We also do activities to strengthen L and O's muscles in their hands. Their most favourite activity is the monster tennis ball. These are very easy to make - you simply need to cut an opening into a tennis ball making sure that it is wide enough to open to represent a mouth but not too wide that the tennis ball splits in half. The idea is that the ball is held between the thumb and pointer finger and you use these two fingers to squeeze the ball to open to put small items into the monsters mouth. This action of squeezing the tennis ball open, strengthens the muscles in the hand that are used for fine motor control.

There are many other options for strengthening a child's proximal stability. The one point to remember is that proximal stability needs to be strong before we start working on fine motor control!

Proximal stability BEFORE distal mobility!


  1. I had never heard of these terms either! You explained them really well though and now I feel like I understand.

  2. Oh wow, I have never heard this before either.. It is so interesting how much there is to learn about autism..

  3. I've never heard about this before, but it makes complete sense after reading your post. This is great info!

  4. Me neither, i can imagine there are so many things that people don't really know about Autism. I think it is still quite new to people and there needs to be alt more awareness

  5. Wow you really know so much about this! I’m sure so many other parents would love to read this that may be going through something similar. Love the games you created to help them!

  6. Thanks for such an informative post. I had no idea about either of those terms and what they could mean for little ones.

  7. How interesting and sounds like you have an awesome occupational therapist!

  8. Wow you really know so much about this! I’m sure so many other parents would love to read this that may be going through something similar. Love the games you created to help them!
    mobility construction


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