Parenting Without Pain: Dressing and Clothing Life Hacks

I am proud to be a guest blogger with the wonderful patient resource Creaky Joints. I am currently writing a series of posts on the topic of Parenting Without Pain. The posts will tackle how parents with arthritis or other painful joint conditions can approach activities of daily living involved in caring for children in a way that minimizes joint pain.

My first topic is Dressing and Clothing Life Hacks. In this post, I cover everything from clothing selection (more zippers, less snaps!) to joint protection strategies, regardless of materials used (such as using a hand splint, as pictured below). See the link here for the full post!


Posted in baby, Occupational Therapy, parenting, Rheumatoid Arthritis, Uncategorized | Tagged , , , , , , , , | 1 Comment

Childhood Memories and Lessons that Influence my Work as a Pediatric Occupational Therapist: Part 1

Reflecting back on my main priorities in elementary school: horses, and soccer.

Reflecting back on my main priorities in elementary school: horses, and soccer.

While working with school-aged children, I often find myself reflecting on how I saw the world and what was important to me as a child. Accessing childhood memories helps me identify with a child’s perspective, even if that child has a specific disability or challenge that I did not experience.  When I find myself mystified by a child’s behavior or perspective, I conjure up vivid memories of what it was really like to be a child; remembering the complexity of my social, emotional and academic experiences helps build a crucial bridge of empathy between myself and my students. 

Below, I will share lessons inspired by childhood memories that influence my daily work as a pediatric occupational therapist. My lessons are geared towards older elementary aged students who are mostly in the general education setting, as those are the children with which I currently work most often.  I had such a large flood of memories while working on this post that I decided to break it into two parts; part two will address the complexity of social relationships and more.

  1. The Importance of Connecting with a Child’s Emotional Response to their Performance.  During my elementary school years, I had an unabiding love for horses and a concurrent interest in drawing. As I grew older, I became increasingly frustrated with how badly my drawings looked compared to my vision. I had a very specific image in my mind of how I wanted to draw a horse (see below, left). However, the outcome of my drawings often looked far inferior (see below, right).  I remember sitting in the library with one of those “How to Draw” books, trying over and over to draw a good horse drawing, and never getting close to my ideal.
My ideal of a good horse drawing

My ideal horse drawing

My actual horse drawing

My actual horse drawing







Adding to my frustration and confusion, I found that adults would often praise my drawings as “so pretty!” As someone who took the opinion of adults seriously, I struggled to reconcile their positive assessment with the obviously incongruous reality. I remember concluding that they simply didn’t love horses as much as I did, so they were not attuned to the vast difference between my output and my ideal horse drawing.

The ability to accurately self-assess one’s work is a developmental skill that not all children realistically will have in elementary school. However, I can take a broad lesson from this memory: when there is a chasm between what a child does and what they aspire to do, an adult can serve the vital role of empathizing with the emotion associated with their performance, rather than attempting to soothe them or asserting that their performance is better than it is.

Attempts at horses, people, and birds

My childhood attempts at horses, people, and birds.

As an OT, I am constantly providing children with the “just right challenge,” just outside their current ability. I may rejoice clinically in their small steps towards improvement, but the child might not see it that way; they may remain frustrated, even if the incremental steps they are taking are objectively significant to me. I have to differentiate my pleasure in their progress from theirs, and identify with their feelings related to their performance in order to fully support the whole child.

This principle is well outlined in the classic book, “How to Talk so Kids Listen and Listen so Kids will Talk.” The main point is to empathize with a child’s current state and reflect it back, rather than negating it or immediately jumping to solutions. For example, if a child shows an adult a piece of work the child is unhappy with, the adult could reflect back to them by saying something like, “You’re frustrated your drawing doesn’t look how you want,” rather than, “That’s a beautiful drawing!”

I hope that the benefits of doing this are self-evident, but in case they are not, here are some reasons that this approach is beneficial therapeutically:

1) Empathizing with a child’s self-assessment not only honors the child’s feelings, it also helps strengthen the therapeutic bond between us, as the child may feel more connected and engaged due to my honoring their perception.

Just right challenge - toddler version

Having a toddler has been good practice for linking developing motor skills to frustration!

2) In examining a child’s emotional reaction to a task, I can more competently address the barriers to their success. For example, if a child is struggling with learning how to zip up a jacket or button their shirt, they might have an outburst of frustration that is more deeply rooted than it initially appears. If I open the conversation to the emotional aspect of their reaction to the task and hold space for them in the moment, I might unveil that they are frustrated because, “My little brother can already do this but I can’t, why are things so hard for me?” or “My fingers don’t work!”

As occupational therapists, we often address motor dysfunction, but I’ve found the bigger barrier to success is often the frustration built from years of feeling like a failure, or feeling confused as to why things aren’t fluid and automatic for this child, as opposed to others. In addressing the emotional component rather than focusing solely on “motor strategies,” I can address a deeper element that might free up mental space for them to ultimately achieve their motor goal more successfully. For example, I’ve had conversations that started about letter reversals for b/d, then quickly transitioned to conversations about why other children “think I’m stupid” or “don’t want to be my friend.” Everything I ask a child to do is hard for them in some way; otherwise, they wouldn’t need therapy. Doing something you’re not naturally good at is intrinsically a frustrating experience for most people, so I try to keep the emotional aspect in the forefront of my mind, even if the specific goal I am addressing is not emotionally rooted. I find that occupational therapy’s roots in mental health are a huge asset for our profession in this respect. 

3) If my own reflections didn’t convince you, consider recent research that emotions are integral to learning. As the author of the article states beautifully, “Emotions are not add-ons that are distinct from cognitive skills. Instead emotions, such as interest, anxiety, frustration, excitement, or a sense of awe in beholding beauty, become a dimension of the skill itself.” (Mary Helen Immordino-Yang). In other words, emotions are an important part of the learning process, thus they should not be shoved aside when working on non-emotional goals.

2. Children Need to Know Why They are Being Asked to do Something, or Otherwise Find Meaning in the Task at Hand.

Two of the things I loved most as a child, together in one photo: horses, and Pippi Longstocking

Throughout elementary school, my favorite movie was “The New Adventures of Pippi Longstocking” (see the trailer here).  Pippi is a free spirit whose re-introduction into traditional western society after years of living with her father on a sailing ship leaves her frequently confused. While attending school classes for the first time, she quickly becomes distressed. After misinterpreting her teacher’s questions, she tearfully asks, “Why do they ask questions when they already know the answers?” She genuinely doesn’t understand why she’d be asked to solve a problem that a teacher has already solved. 

Now, most children who have attended school from a young age understand the cultural norm that in school you will be asked questions to demonstrate your knowledge, as part of the educational process. Regardless, I keep Pippi’s experience in mind because children need to know why they are asked to perform a task or demonstrate competence. 

My sister and I were teacher's pets, but still needed to understand why we were asked to do things some of the time.

My sister and I were highly motivated to please our teachers, but still needed to understand why we were asked to do things some of the time.

In OT, our end goals are usually functional life skills where the purpose or meaning is self-evident. For example, we help a child learn to hold their pencil correctly so that they can write most efficiently with it. However, we often work on sub-skills that don’t have an obvious connection to our end goal. For example, we might have a child cross the monkey bars and complete Theraputty exercises to improve their hand strength, provide additional proprioceptive input into their hand joints, open their web space and improve body awareness prior to handwriting, to improve their long term writing endurance and precision. 

Most children I work with don’t hesitate to question why I’m asking them to do something, particularly when it’s difficult for them. When I take the time to explain the purpose of their OT activities, I get increased buy-in, engagement and compliance on the part of the child. It may feel momentarily frustrating when a child questions why I’m asking them to do something or appears to resist or defy my suggestions, but I try to really challenge myself to maximize everything I can do to help the child find meaning in the task at hand. I find that the three core innate psychological needs outlined in Self-Determination Theory are critical for me to remember when a child is struggling with motivation: competence (the drive for mastery), relatedness (the desire to connect with others) and autonomy (the need for self-determination or to actively make choices). Usually I can find a nugget of inspiration to draw from by supporting or addressing one of those three core needs. 

To explore a topical example in depth: over the last few years, some children have asked, “Why do I need to learn to write by hand if I’m going to spend most of my life typing?” There is a huge international ongoing debate within the occupational therapy and education communities about the role of handwriting in elementary school. 

I'm a big fan of keyboarding, but even I admit that 1 years old is a bit young to start!

I’m a big fan of keyboarding, but even I admit that 1 years old is a bit young to start!

 Considerable research indicates that handwriting skills are correlated with improved literacy and retention, thus all other things being equal, I see the case for writing by hand. However, all other things are not equal for most of the children I see. Many children referred to OT have significant barriers that make writing by hand much more challenging than expected. These barriers include visual or fine motor delays (such as Developmental Coordination Disorder),  language based learning disabilities such as dyslexia or Specific Learning Disorder with Impairment in Written Expression (sometimes known as dysgraphia, which can be confusing because dysgraphia can also refer to writing legibility impairments that are rooted in fine motor delays such as Developmental Coordination Disorder), executive functioning and/or attention challenges (such as ADHD), spatial reasoning difficulties, and more. When these barriers exist, I help the child and their family make the difficult decision of whether the benefits of writing by hand are strong enough to justify engaging in the laborious process of remediating their handwriting skills, when they have a potentially effective workaround right at their fingertips in the form of a keyboard.  

At a recent training on disorders of written expression by Dr. Steven Feifer (whose numerous books on learning disabilities can be found here), I was floored to learn that according to neuro-imaging, written expression is the number one most taxing school activity for a child’s brain, with reading and math being close behind. Dr. Feifer made the case for using accommodations such as typing for children with disorders of written expression in particular, to free up “brain space” that was formerly devoted to the visual-spatial and motor demands of writing by hand. Keyboarding allows for more neurological real estate to be devoted to the higher level executive functioning aspects of written expression such as language processing, organization of thoughts, prioritization, working memory, sustained attention, response inhibition, and more.  

My own writing sample from 1st grade (spoiler alert: I LOVED handwriting).

My own writing sample from 1st grade (spoiler alert: I LOVED handwriting, and expressing myself in any medium possible).

Keeping all this in mind: in deciding whether to support the child’s handwriting skills or focus on alternative strategies for written expression such as keyboarding, I must take into account not only the child’s context/environment, age, available technology tools and the extent of their underlying challenges, but also their personal values and preferences with respect to written expression in order to address their need for autonomy. Over the last few years, some students with whom I work have been highly motivated to type, and absolutely flourished with the use of school accommodations such as, “The child can type any assignment of more than 2 sentences.” The option to type has removed considerable frustration and anxiety for these children, and has allowed them to express themselves more fluidly and competently. 

I’ve also enjoyed helping other children remediate their handwriting skills, which often brings other secondary benefits. For example, if the underlying barriers are more of a visual-spatial and/or fine motor nature, improvements in these areas will logically extend to many other areas beyond writing. These students worked incredibly hard to remediate their handwriting legibility and speed, and they enjoy the many benefits of writing by hand.

In either case, I have found that when the child has some say as to which approach is taken, there is a sharp increase in engagement and compliance during our sessions. As a child, I was extremely motivated by relatedness; for me, connecting a task to a social outcome was essential for my engagement. However, some students I work with are not quite so socially motivated, and I need to address motivation and engagement from different (sometimes more creative) angles. To learn more about how to address motivation and meaningful engagement in your sessions, consider one of the evidence-based books on the topic such as the Art and Science of Motivation: A Therapist’s Guide to Working with Children, or Goal Setting and Motivation in Therapy.

Concluding thoughts

Growing up in the 1980s: all about the Cabbage Patch dolls and Care Bears.

Growing up in the 1980s: all about the Cabbage Patch dolls and Care Bears.

The world that children today are growing up in today is very different to the world I grew up in during the late 1980s, when playing “Oregon Trail” at the computer lab was the most exciting technological part of my day, and the Encyclopedia Britannica seemed to hold the entirety of the world’s knowledge. Despite the change in technology tools and access to information, many aspects of the learning process and environment have remained unchanged, such as the benefits of adults empathizing with a child’s emotions, and the need to demonstrate why a task or skill is important for a child to acquire. In reflecting on my childhood experiences, I find myself in a better position to identify and address the emotional or motivational barriers a child might be experiencing. I look forward to hearing your reflections and comments as well!





Posted in Occupational Therapy, parenting, pediatric occupational therapy, social emotional learning | Tagged , , , , , , , , , , , , , , , , , | 2 Comments

A New Way to interpret the “But You Don’t Look Sick” Response

I am happy to report that in addition to blogging here, I am now also blogging on the wonderful Creaky Joints website. Creaky Joints provides an invaluable forum for information sharing, support, and advocacy resources for persons with arthritis and related conditions.  My first blog post is A New Way to Interpret “But You Don’t Look Sick,” an excerpt of which can be found below. I look forward to more posts, which will include occupational therapy-specific strategies as well as tips for parenting while managing autoimmune-caused arthritis. If you have any ideas for future post topics, let me know in the comments section!

Can you tell who is “sick” by looking at this picture?

“When I communicate my diagnosis of rheumatoid arthritis to someone for the first time, I’m often told that I ‘don’t look sick.’ Many people understandably feel that being told they don’t look sick is delegitimizing. It is easy to interpret the statement to mean, ‘You don’t LOOK sick, so you can’t really BE sick.’ This is particularly tempting for invisible illness sufferers, as most have struggled to get appropriate diagnoses and have at some point been told that their disease was all in their head….

It is understandable that those of us with invisible illnesses feel defensive when we are told we ‘don’t look sick.’ However, sometimes the statement is really more about the speaker needing a little time to process this news, than it is a lasting statement or critique of the patient.I see the statement as more about the person learning this information going through a rapid mental process of surprise, disbelief, and acceptance, rather than them deflecting or minimizing the speaker’s reality. In that moment, I have a choice about how I can interpret their statement that I ‘don’t look sick;’ I can be defensive, or I can see that statement as a bridge to their ultimate acceptance/learning about the disease. I often say, ‘I know, I don’t feel like I look sick either, but I guess you just can’t tell from looking at someone, right?’ and then I offer to answer any questions they may have.”

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The Storm After the Calm: 8 Lessons Learned After A Tumultuous Postpartum Experience With Rheumatoid Arthritis

Having a baby while managing a complex autoimmune disease: about as tiring as I look in this picture, but also as happy/sweet as Charlie looks.

Having a baby while managing a complex autoimmune disease is tiring at times (as my face shows) but also sweet and joyful (as Charlie’s face shows).

I was recently honored to be asked to share my pregnancy and postpartum journey with the popular and helpful website Autoimmune Mom. The full story can be found here. The post details my journey from a relatively tranquil pregnancy to a postpartum “storm.” It includes three sections after Charlie’s birth: 

1) Survival, Mastitis and Flare-Ups (0-3 months)

2) Feeling Like I “Almost Got This,”or Wayward Optimism (4-16 months)

3) The New Normal: Accepting that life/parenting/my health is now in a permanent state of flux (16 months to present).

Ideally, the full post should be read in order for the ultimate lessons I have learned to make sense in context.  For those who might not have time to read it all, I wanted to provide three of the 8 lessons I learned through the process of seeing a clinical psychologist (the rest of which are detailed on page 3).

Lesson 1): The therapeutic relationship has been more powerful than I anticipated. Regardless of the “outcome” of a visit (e.g., whether or not I can put into practice the things we discussed), the time we spend is meaningful and therapeutic in and of itself. I have felt validated and listened to in a way that feels different and sometimes more powerful than I have experienced elsewhere. In addition, checking in with my therapist weekly gives an emotional anchor to my week, a consistent time I can depend upon to reset and devote time to examining my life in a structured way. I really recommend therapy to anyone who might be on the fence about it.

Lesson 2): Creating a mental/physical health timeline helped me see patterns in ways I couldn’t previously.  I created a timeline of the 4 main intertwined mental and physical health issues of my life (autoimmune/RA activity, stress/anxiety events, loss of appetite, and claustrophobia/panic attacks), and color coded them (COLOR CODING FOR LIFE!). With this chart, I saw for the first time how all the aspects of my life are intertwined in ways I had never connected before (see picture below for an excerpt from years 1981-2007). I understand now that when my physical state is less than ideal, I have a much harder time coping with stressful events and any underlying anxieties. I think it would be an interesting exercise for anyone dealing with a chronic health issue.

Doc - Nov 18, 2015, 8-46 PM

Lesson 6: Accepting rather than deflecting emotions.  One of the hardest parenting adjustments for me, aside from health issues, is how quickly my emotions swing from highs to lows and back. One minute I may be dreading wrangling my squirmy 30+ pound toddler into his car seat because it hurts my hands, but then a split second later he might start singing in the sweetest voice I’ve ever heard, or doing something else that melts my heart, and I have to make sure to pause and drink in those moments, because the next minute later he might be throwing a toy car at my head.

Traveling with a baby (on a ferry, pictured here) always has ups and downs

Traveling with a baby (on a ferry, pictured here) always has ups and downs

Through the ACT approach, I have learned how to observe my thoughts rather than judging or trying to change them; previously, I would get down on myself for getting irritated or angry, whereas now I am able to accept that those feelings are part of my life, and I can observe those thoughts from a more distant stance. Paradoxically, in accepting rather than deflecting the negative aspects of my current state, I actually feel better rather than worse. Truly being present with my current state (such as feeling pain or just feeling worse than I’d like) has opened me up to feeling more at peace and even happier than when I was attempting to deflect or minimize my experiences.

I am hoping that by reading my story, others may not feel as alone in their journeys. I look forward to hearing others’ comments on the original full story or here!








Posted in autoimmune disease, parenting, Rheumatoid Arthritis | 2 Comments

Why and How Do Pediatric Occupational Therapists Play Games?

Pediatric occupational therapists are often asked why we spend time “just” playing games with our clients. In addition to being engaging to children, games are powerful tools through which we work on a variety of skills including fine motor, visual-motor, gross motor, strength, social, emotional, sensory, and attention, planning and other executive functioning skills.
Tic_Tac_ToeOTs are experts in adapting games to fit a child’s goals. A competent occupational therapist will never “just play” a game with a child. The game itself and many aspects of the game’s set-up will be consciously chosen and adapted on a minute by minute basis so as to support the child’s progression in a variety of areas.

To demonstrate the myriad ways even a simple game can be used to work on a multitude of important skills, I will use the example of Tic Tac Toe (or “Noughts and Crosses”) below. I will separate skills into categories for the sake of organization, but in reality we hardly ever work on skills in isolation and typically target multiple areas with one activity. There are more skills than I can list in one blog post, but I’ve covered many basic skills relevant to OT’s scope of practice that can be augmented through simple games.

Fine Motor Skills

  1. inline-graphic-11Pincer Grasp development: Use small items such as marbles for “x” and “o.” Require the child to use the pincer grasp with their thumb and pointer finger in order to pick the game items up and place them on the board. This helps them further separate the “precision” side of the hand (thumb, pointer and middle finger) from the “power” side of the hand (ring and pinky fingers). Bonus: this also works on hand arch development!
  2. Image credit from this blog post.

    Tongs: Require the child to use a proper grasp on the tongs, which helps them further isolate the “precision” side of their hand. Use fun items for the “x” and “o,” such as different colored cotton balls, beads, game pieces or marbles. Using tongs also promotes an “open web space” which is important for a mature tripod grasp for handwriting. Learn more fun ideas for using tongs in OT at the MamaOT blog here.

  3. In hand manipulation

    In-hand manipulation: Use small items such as coins for the game pieces. Require the child to start with 2-5 coins in the palm of their hand, then “walk” one coin out to their “pincer fingers” (thumb and pointer finger) while simultaneously keeping the other coins tucked into their palm with their middle, ring and pinky finger. This skills is known as “in-hand manipulation.” It is a great activity for continuing to develop the pincer grasp, in addition to improving overall hand dexterity!

  4. Stickers: Require the child to peel off stickers to use as game pieces. This works not only on individual finger dexterity but also bilateral coordination, as the child’s non-dominant hand will hold the sheet while the dominant hand peels off the sticker. Learn more about how to use stickers therapeutically here.

Visual Motor and Pre-Handwriting Skills:

  1. Scissor skills

    Scissors: Before you start the game, require the child to cut out shapes as the game pieces. Selected specific shapes at the next level up from their current level of mastery; for example, if they have mastered a square, progress them to cutting out a triangle. Hold the child accountable to grasp the scissors correctly. Using scissors works not only on fine motor skills but also on bilateral coordination as both hands must work together. Learn more about developing scissor skills here.

  2. Shape development/pre-handwriting: Instead of having a child write Xs and Os, have them draw the basic shapes they are working on mastering. Learn more about the progression of drawing shapes here.
  3. Great picture from Miss Mancy’s blog.

    Vertical Surface: Position the game board on a vertical surface (such as a wall or the underside of a table), which requires the wrist to be in a position of extension (knuckle side of the hand pulled back and facing you, if you are looking at the knuckle side of your hand). As shown in the picture on the right, wax sticks work well, or you can simply use paper and pen/pencil. Learn more about the benefits of working on a vertical surface here and here.


  1. Image credit here.

    Practicing writing specific letters or words: Use “problem letters”or words instead of “X” and “Os,” and require the child to write with the desired legibility criteria. Legibility criteria can include: stroke sequence (the order in which the lines are written in order to achieve the letter), size, horizontal alignment (are the letters “sitting” on the horizontal line or “floating” or “dipping?”), and more.

  2. Pencil grips

    Pencil grasp: Change the type of writing implement used to promote a more mature writing grasp. For example, using small “stubs” of chalk can promote a tripod grasp, as can using pencils with different grips. You can also use the game as a functional activity by which you can try out different pencil grips which will promote a more efficient grasp for your child.

  3. Use a tablet (such as the iPad): There are many apps on which you can play Tic Tac Toe. To specifically work on handwriting skills, I would recommend using a stylus.
  4. Use Tic Tac Toe as a writing prompt: For older children, use a writing prompt such as, “How would you explain how to play Tic Tac Toe to someone who had never seen or heard of the game before?” Apply whatever legibility criteria you are currently using to support improvements in writing performance. This writing prompt would also help work on sequencing, or figuring out how to break an activity down into individual component parts, as well as perspective taking (particularly relevant for persons with an autism diagnosis).

Gross Motor Skills & Strengthening

  1. Toss Across – can purchase here.

    Hand eye coordination: Have the child throw a bean bag at a target in order to select which quadrant they are placing their “x” or “o.” Change how far they are standing away from the target to make the task harder or easier to facilitate the “just right challenge.” There is already a product on the market for this concept, called, “Toss Across,” or you can make your own version by following the guide here.

  2. Balance: Play the traditional paper way but stand on a BOSU ball, balance ball or other unstable surface to improve balance. As always, grade the task by providing different levels of assistance (physical or verbal cues) to help the child reach the next level up of competency from where they currently are.
  3. Awesome home made Lego Tic Tac Toe board from this blog.

    Finger/hand strength: Use resistive items for the game pieces such as different colored clothespins or even Legos on a Lego Board (see the picture on the left!).

  4. Shoulder girdle strength: Working on a vertical surface helps strengthen the shoulder girdle, especially if you work against gravity by positioning the board on a wall or on the underside of a table.

Social Skills

  1. Social rule following: Any game can be used as an opportunity to understand and follow rules. Set appropriate ground rules before game, such as, “We wait our turn, we don’t offer feedback or suggestions to others unless we are asked, we say ‘good game’ or ‘thank you afterwards.” Hold the child accountable to following those by offering gentle reminders if they are not followed.
  2. Social Skills, image credit here.

    Perspective taking: Have the child explain the rules to another child, or do an assignment where they “Explain the game of Tic Tac Toe to someone who’s never played so that they understand it.” This forces the child to consider what it’s like to not know what they know, which is a skill that generalizes into many other social contexts. This assignment works really well for games/activities that the child may really love, such as Minecraft. It can be graded up or down (made harder or easier) by the adult “scaffolding,” or giving them hints or leading questions to help them come up with the desired answers.

  3. Deciding who gets to go first: Learning to negotiate who goes first in a game is an important skill for children. Depending on the child’s level, you can model various ways to choose who goes first (for example, you can have the child whose birthday is coming up soonest go first). As they grow in their social skills, encourage them to take more responsibility/ownership of making these decisions without an adult’s help.
  4. Reading facial expressions: Use game pieces comprising different facial expressions, and discuss what those expressions represent as you play. You can integrate fine motor/handwriting skills into this version if you have the child first color and then cut out the pieces.

Emotional control and self-regulation skills

  1. Waiting one’s turn in general is a great way to work on frustration tolerance; open source image credit here.

    Apply self-regulation program language and tools: While playing the game, apply language from a self-regulation program such as the Zones of Regulation, Superflex, or the Alert Program. Apply labels to how you feel first, then show how you (the adult) use a tool to regulate your emotions. For example, you might say, “I just lost my turn, I feel frustrated and in the yellow zone.  I’m going to take 3 deep breaths to feel more calm and in the green zone.” The Superflex program has a great “unthinkable” (villain that invades your brain) called “DOF: Destroyer of Fun,” who gets into your brain and makes you overly competitive. The program helps walk children through strategies to “defeat” DOF, which I find particularly helpful! It is effective for some kids to depersonalize what is happening; saying that “DOF invaded my brain and now I have to defeat him” is less personally threatening than saying, “You’re getting too competitive, you need to figure out a way to stop now.”

  2. Frustration tolerance: Modulate whether you or the child wins, whether they are playing with preferred or non-preferred items, and other aspects to help them work towards becoming more tolerant of frustration.

Sensory Processing Skills

  1. Tic tac toe with soap or shaving cream is super fun!

    Tic tac toe with soap or shaving cream is super fun!

    Change the materials: Use X and Os with specific tactile input that challenges the child just outside their comfort zone to promote a wider sensory repertoire. For example, if they are very averse to sticky textures, require that they draw some of their Xs and Os with finger paint or shaving cream rather than pencil and paper, and increase that requirement over time. This can be done for aspects other than tactile defensiveness, but I mention a tactile example because they tend to be the easiest to visualize.

  2. Feeding issues: Use different food items for the X and O pieces. Select items according to the priorities for increasing your child’s food repertoire; learn more about how to approach feeding issues here .
  3. Change the environment: Modulate the environment (lighting, auditory distractions, visual distractions, smell distractions) either to help the child expand their tolerance of different input, or to make the child more comfortable so that you can best position them to succeed while you work on other areas. For example, if I am really trying to isolate fine motor skills and the child is very distracted by auditory and visual input, I will take them into a smaller and quieter room in our clinic so that they will be less distracted and thus better able to focus on fine motor requirements.

Executive Functioning Skills (not including emotional control, which is covered earlier); particularly relevant for an ADHD diagnosis

  1. Working in a crowded room can be a good challenge for one’s attention, but for some children it will be overly stimulating. Image credit here.

    Sustained attention: Challenge the child by playing in a difficult environment for them, such as a loud classroom. Take care to challenge them just beyond their current level of competency; this is known as the “just right challenge.” For some children, playing in the presence of 1 additional person would be very challenging, whereas others are ok with 2-3 others in the clinic but have difficulty with 4 or more. Others will find the challenge not in the number of children present but in how loud the environment is overall. You can also challenge their attention by holding them accountable to attend to whose turn it is and take their turn without a reminder. Becoming competent in sustaining attention is a vital life skill, so I try to always consider the attention demands of whatever activity I’m doing with a child, and assess whether there is a good fit between the child’s ability and the activity demands.

  2. Planning the board game can be especially motivating if food is involved! Image credit here.

    Planning/organizing: Have the child plan some or all aspects of the game’s set-up. To make this task easier, give them a set of materials/parameters to work with, such as: “We have to use one of these 4 food items as the game pieces, and a board the size of a 8×11 piece of paper or smaller.” To make the planning/organizing aspect harder, provide a more open ended structure, or introduce the presence of other executive functioning demands such as a time constraint which adds the skill of time management, or the presence of distractions which would upgrade the attention demands.

  3. Response inhibition: Hold the child accountable to inhibiting extraneous talking, touching of materials or impulsive movements (such as starting their turn before the current person has finished theirs). As with all of these modifications, fit the task to the child’s unique challenges.
  4. Working memory: Obstacle courses are a great way to work on working memory. For example, you can ask a child to perform a series of 3 different actions before taking each turn on the tic tac toe game, regardless of how it is set up. This will challenge their working memory. If 3 is easy for them, then upgrade the task to 4, and if 3 is too challenging, downgrade it to 2.


A rare picture of me at work :-)

A rare picture of me at work 🙂

It’s crucially important for occupational therapy professionals to be competent in explaining to parents/teachers/caregivers why we have selected a specific game and set it up a certain way in order to work on improving foundational skills. As a lay-person, you can play a game without attending to various task demands and the game can simply be a way to pass the time. If the game is set up by a professional who is constantly manipulating various aspects to make it the “just right challenge” to help the child achieve crucial life skills, it can be a powerful tool to help a child function better and achieve their goals. My goal is always to make therapy as fun and engaging as possible for my clients, but that is never at the expense of working on foundational skills. I hope this post has helped show you how simple games can be used therapeutically by occupational therapists! Please share your additional ideas for adapting games in the comments section.

Posted in kids activities, Occupational Therapy, parenting, pediatric occupational therapy | Tagged , , , , , , , , , , | 9 Comments

My Chronic Illness Playlist

Charlie and I love to dance together - photo credit

Charlie and I love to dance together – photo credit

While managing my autoimmune disease rheumatoid arthritis over the last 12 years, I’ve found music to be helpful in a variety of situations. Some songs help me calm down when I’m anxious, other songs allow me to just “be” in a sad moment, and some music inspires me or puts everything in perspective. Not surprisingly, research has shown that listening to music can have many positive effects on one’s mood as well as other aspects of the mind.  Research specifically on the use of music in persons with chronic illness have found it to have beneficial effects as well.

With that in mind, I’d like to share my personal “chronic illness playlist.” I’ve divided the songs into groups based on when I have found them most helpful/appropriate, with some bonus stories/analysis regarding how I relate to them. I would love to hear your favorite songs for chronic illness or managing other difficulties in the comments!

Sad-ish songs for when you need to just feel what you’re feeling:

Although I often strive to see the positive side of difficult situations, I strongly believe there’s a value to being present to what you are feeling without attempting to push yourself into a different direction. There is mounting evidence that mindfulness training can lead to benefits in mental and physical health.  Sadness and other negative feelings are intrinsic parts of the human condition and it can be therapeutic to listen to music that makes you be present for the feelings of sadness that accompany living with a chronic illness.

1)  Why – Annie Lenox 

Choice lyrics: “This is the book I never read, these are the words I never said, this is the path I’ll never tread, these are the dreams I’ll dream instead. This is the joy that’s seldom spread, these are the tears, the tears we shed. This is the fear, this is the dread, these are the contents of my head.”

This is one of my all time favorite songs. I relate to it from the break-up perspective as well as from the chronic illness perspective. I think anyone diagnosed with a chronic illness at a young age goes through a stage where they question, “Why?” There will usually never be an answer; I did all the “right” things by exercising, eating well, etc, and while we like to think that controlling those variables will ensure good health, it’s simply not true. Bad things happen to people who do the “right” things all the time, and there just is no rhyme or reason to it. Logically knowing that, however, won’t always stop us from asking or wondering “why” this is happening.

The section I quoted above really speaks to me…I’m the kind of person who has a life to-do list that stretches miles long, and it bothers me sometimes that RA can be a limiting factor (“this is the path I’ll never tread”). That being said, I do comfort myself with the thought that even without RA, I would never be able to achieve everything I want to do in this life because I have limitless desires/interests. There are many paths I’d like to tread which I will not be able to, partly because of RA but mostly due to mortality and my limited time here on earth!

2) Two – The Antlers   

Choice lyrics: “You had a new dream, it was more like a nightmare. You were just a little kid, and they cut your hair. Then they stuck you in machines, you came so close to dying, they should have listened, they thought that you were lying.”

This song really hits home for me personally, as my path towards a diagnosis was winding and fraught with delegitimizing comments from healthcare professionals (who implied to my parents that I was covering up an eating disorder and later suggested I was “just stressed”). I am always hesitant to play “Monday morning quarterback” with my health providers, as hindsight is 20/20 and it’s not fair to say that my providers should have necessarily made the mental leap from my symptoms to my diagnosis in the early days. I understand the complexity of the system now as a provider as well. However, I will say that I was not always treated with the seriousness that my eventual diagnosis would suggest I deserved, and I will never forget the stark loneliness and fear I felt when it seemed no one wanted to help me get to the bottom of my health issues.

This song also touches on the impact of a chronic condition on loved ones. The overall tone of the song and album (see this article to learn more) is a lot sadder and reflects a much more complicated relationship than I have had with significant others, but I identify with the fact that at the end of the day, it can feel like it’s just you and the significant other facing the daily reality of living with chronic illness.

Before moving on to the next song, I just have to add/stress that the “Daddy” lyrics of this song in no way apply to me or my family. I am fortunate to have had rock solid support from my family and loved ones since my diagnosis, and in fact I might not have been diagnosed nearly as soon as I did if my parents hadn’t been so proactive.

3) Hide and Seek – Imogen Heap 

This song really captures the surreal feeling of dealing with something unexpected or disappointing in life, whether that be a break-up, health condition or other adverse circumstance.  It’s one of my go-to songs to pump up in the car while processing bad news or difficult situations.  I don’t have a ton more to say about this song, I just love it!

4) Stars – Grace Potter and the Nocturnals 

Choice lyrics: ‘All those times we looked up at the sky, looking out so far, it felt like we could fly, and now I’m all alone in the dark of night, and the moon is shining, but I can’t see the light. And I can’t look at the stars…”

This song is just perfect.  I really relate to the lyrics above as they capture the transition from feeling invincible (prior to health problems) to recognizing the fragility of life. In case anyone is interested, the backstory of this song suggests it was written about the loss of a friend, and I think many can relate to it on that level as well.

5) Out of the Woods – Taylor Swift

Taylor Swift once said that she aimed for each song on her album 1989 to capture the feeling or emotion that she describes lyrically, and I think this aim is achieved with stellar results on, “Out of the Woods.” Many people with chronic illnesses can identify with the repetitive, pulsing question: “Are we out of the woods yet?” with respect to their health. One of the hardest aspects for me to manage about rheumatoid arthritis is not knowing when I’m truly “out of the woods.” Even if my medication is working, I don’t know whether or when it will stop.  Many of the most effective biologic medications work well for a few years, and then the body’s immune system adapts to them and you have to try another one (this has happened to me once already). There is not a good video of the original version of this song, so I have linked to where you can listen to it and purchase it if desired.

Additional songs to check out that didn’t make my top 5 include: Parachute by Guster, which has a beautiful build to it (“It crept up on me, ignored all my pleas, begging to leave, no justice to name me. Fell out of the sky, cease it to be, without a reply, gravity fails me”);  Her Diamonds by Rob Thomas (of Matchbox 20 fame), which was written about his wife’s battle with an autoimmune disease; Eyes Open by Taylor Swift, which has a nice line about “everybody’s waiting…for you to break down;” and Jolene by Ray Lamontagne, which is just haunting and beautiful.

Calming songs:

The following songs have helped me feel more calm or grounded, particularly when I’ve been in an anxious state. They have been most helpful when I have recently received bad news.

1) Keep Breathing – Ingrid Michaelson  

This song is simply gorgeous. Ingrid Michaelson’s voice is beautiful, and the repetitive, hypnotic nature of the lyrics works well for reminding me that sometimes, all you can do is keep breathing.

2) Hold On – Tom Waits 

Choice lyrics: “Well your old hometown is so far away. But, inside your head there’s a record that’s playing, a song called hold on, hold on, you really got to hold on. Take my hand, I’m standing right here and just hold on.”

I just love Tom Waits’ gravelly voice. “Hold On” is also hypnotic and repetitive, which works to put me into a bit of a trace.  “Hold On” tells a pretty detailed story, but even if you don’t relate to the story, I think you can relate to the main chorus and message to “hold on.”

3) Orange Sky – Alexi Murdoch 

This song is also very hypnotic and calming to me. It reminds me that my “salvation” or the cure for my anxieties at times is love; in my case, I imagine the love I have for my family and friends, but I expect others may relate to it from a religious perspective as well.

4) Hoppipolla  -Sigur Ros

Hoppipolla is Icelandic for, “jumping into puddles,” and on some level I just love that imagery. I really respond to the overall tone of this song, and it has personal relevance to me as I walked down to aisle to it at my wedding in 2012.

5) Teardrop -Massive Attack  

Choice lyric: “Love, love is a verb, Love is a doing word, Fearless on my breath…”

“Fearless on my breath” is a beautiful sentiment; I love the image of being fearless in the face of adversity. Of course, I have a positive association with this song as it is the theme for the TV show “House,” which depicts many complicated medical conditions which people with chronic illness can relate to (although many of the cases are more acute than chronic). There’s a nice repeating theme of, “Is it lupus?” throughout the show, which brings light/awareness to the fact that autoimmune disease are notoriously hard to diagnose (in other words, it always  could be lupus).

6)  Dreaming my Dreams – The Cranberries  

There is just something about this entire Cranberries album that is very relaxing and calming to me, although I will admit that many of the songs have a bit of a somber tone. This one is perhaps the most optimistic and calming to me.

Inspirational Songs:

The following are songs that help me focus on the positive, either through lyrics, overall musical tone or both.

1) With Every Heartbeat – Robyn with Kleerup 

Choice lyrics: “Still I’m dying with every step I take, but I don’t look back. And it hurts with every heartbeat…”

There’s something hypnotic about the way Robyn sings, “And it hurts with every heartbeat,” especially from minute 2:40 through to the end. I think this song provides a beautiful mantra for people with chronic pain or illness. Yes, she emphasizes that it hurts with every heartbeat, but I’m still classifying this as inspirational because of the emphasis on not looking back, and the overall uplifting tone of the song.

2) The Remedy – Jason Mraz 

Choice lyrics: “I won’t worry my life away…You can turn off the sun but I’m still gonna shine and I’ll tell you why, Because the remedy is the experience…”

This song was allegedly written about Jason Mraz’s friend’s battle with cancer, and it has some explicit references to battling illness (such as “we will cure this dirty old disease, ’cause if you got the poison I got the remedy”). This song definitely inspires me to not “worry my life away,” and focus on the real experiences possible to me at any moment.

3)  Another Day – RENT Original Soundtrack 

Choice lyrics: “There’s only us, there’s only this. Forget regret, or life is yours to miss. No other road, no other way…no day but today.

This is definitely one of my personal anthems. Similar to “The Remedy,” it inspires me to focus on the moment and not get wrapped up in worrying about the future. The musical “Rent” has a lot of positive messages in it, for those who are interested!

4)  Feel again – One Republic   

This song simply pumps me up, and I love the sentiment of, “I was a lonely soul but that’s the old me.” It obviously relates more directly to a romantic situation than chronic illness, but I like thinking about being in a better place than the “old me,” moving forward in a positive direction.

5) Man in the Mirror – Michael Jackson 

Choice lyric: “If you want to make the world a better place, take a look at yourself, and then make a change.”

Yes, this song is corny, but it has such a profound message about starting with oneself if one wants to see a better world. Having a chronic illness can easily make one feel a lack of agency, yet we always have the freedom to choose at least our attitude and our actions towards others. This song also reminds me that whatever I am suffering in the moment, I can still make the world a better place for others who might be suffering in different ways.

Songs that just make you happy:

The songs in this category are the most subjective and personal, so likely these won’t be as relatable to others as the songs listed above. Still, I think it’s important to point out the therapeutic value of that stock of songs that just makes us happy for some reason! That reason could be a nostalgic happy memory, the overall tone of the song, the lyrics, or a combination of the above. I suggest creating a playlist called “happy mix” for when you need to either sustain a happy mental state or inspire yourself to get into one, whether the reason is related to chronic illness or not! Here are just a few on my happy list:

1) King of Wishful Thinking – Go West   

I was one of the first of my friends to get my driver’s license, and I have many fond memories of blasting this song on trips to the mall in the late 90s.

2) Now You Has Jazz – Louis Armstrong and the All stars live at the Newport Jazz Festival

As this is my personal “happy list,” of course I cannot leave out any jazz music! I have spent many happy evenings on the dance floor moving and shaking to infectious swing music. Something about Louis Armstrong’s voice just makes me happy. This particular video includes footage of some current swing dancers as well, for bonus happy points!

3) My Girl – The Temptations 

You really can’t go wrong with Motown or Soul music. This song always brings a smile to my face!


I remember reading The Songlines in college, where Bruce Chatwin casually mentions that humans might have spoken our first words as songs, to the rhythm of our own walking. That always stuck in my mind as a beautiful image, and now that I have a child, I have witnessed how primal the human reaction to music is. I was absolutely shocked when my 11 month old started bouncing, smiling and shaking to music for the first time, completely unprovoked by my husband or myself.  Music clearly has a deep effect on our mood states, and I urge all with chronic illness to consider using music’s effects to support their needs. To learn more, check out the American Music Therapy Association.

Posted in Rheumatoid Arthritis | Tagged , , , , , , , , | 1 Comment

Bringing Home Baby Without Breaking Your Body (or, “Shopping With Arthritis: Baby Care Items and Strategies”)

Although I was predisposed to thumb pain by having arthritis, I could have prevented more of it by holding my baby with my thumb tucked next to my fingers rather than in the position you see here!

Although I was predisposed to thumb pain by having arthritis, I could have prevented more of it by holding my baby with my thumb tucked next to my fingers rather than in the position you see here!

Despite infants’ diminutive size and stature, caring for a new baby is a very physical job! Many new parents and caregivers experience joint or muscle pain after repetitive stress caused by lifting, carrying, diapering, and holding their baby. It’s estimated that between one quarter and one half of new parents experience DeQuervain’s tenosynovitis (or “Mommy thumb”) alone, not to mention pain in other areas such as the wrists, shoulders and back. These issues are of course exacerbated by chronic underlying illnesses such as autoimmune arthritis.

From my experiences as a new mom with rheumatoid arthritis and from my training as an occupational therapist, I would like to share tips on my favorite baby items and strategies that can help preserve the caregivers’ joints and muscles*. I will highlight general “joint protection strategies” in orange as we go along.  This comprehensive guide to joint protection strategies for persons with arthritis has particularly helpful pictures to illustrate the safest way to perform daily activities. I strongly recommend you also read the following articles, which provide a nice overview of proper body mechanics to prevent pain and strain from bringing home baby.

Baby Clothes & Swaddles

This was one of my favorite outfits - easy zipper, stretchy material, plus it's a one piece! Charlie loved it too.

This was one of my favorite outfits – easy zipper, stretchy material, plus it’s a one piece! Charlie loved it too.

If you’re anything like me, you’ve probably oohed and aahed over your fair share of baby clothes. They are so irresistible, from the little overalls to the teeny tiny socks to the baby animals stitched into every corner!  If baby clothes were as easy to put on and off as they are cute, the 12-14 diaper changes a day during the first couple months would be a heck of a lot easier. Unfortunately, baby clothes often come with a mind boggling assortment of small closures, which can be difficult for those with joint pain (especially as the baby gets older and squirmier during changing time!). The most important clothing considerations for me have been:

    1. Resistance: How stretchy is the material? Clothing items with stretchy neck and arm, leg and waist openings are much easier to manipulate and get onto your child without causing excessive strain on your joints.
    1. Tightness of fit: It is easier on my joints to dress Charlie in clothes that are slightly loose rather than tight. Take care, however to stick to outfits that are snug around the upper body and neck to avoid a smothering hazard while they sleep.
    2. Closures: How is the clothing item secured – zippers, snaps, velcro, buttons or something else? I have come to prefer zippers and velcro as they require much less stress on my thumb and finger joints and are also quicker to take on and off than snaps or buttons. For the uninitiated: most clothing items have either zippers, snaps or buttons, most bibs have either snaps or velcro, and swaddles tend to have either zippers, velcro or snaps. Please see the chart below for my opinion of the relative ease of different closures.





Easy on the finger/thumb joints?





Quick to take on/off





Keep baby’s top warm while you change diaper





I'm all about the zippers!

I’m all about the zippers!

The main reason snaps are harder than zippers/velcro is that the action required to fully “snap” them together requires direct force to the thumb and finger joints, whereas with zippers/velcro you are holding the material in a static position and using your larger joints/muscles to create the motion required to secure them. So, the recommendation for using velcro/zippers over snaps falls under the joint protection strategy of “always use bigger/more joints when possible rather than requiring your tiny hand joints to absorb the main force of an action.”

I recommend that if you have outfits with snaps, consider just snapping the middle of the 3 snaps to save some stress on your joints. Additionally, not all snaps are created equal; some are easier to snap and unsnap than others, so test them out before selecting clothes for your little one. I completely avoid items with buttons with the exception of special occasion clothing, since they can be so cumbersome to secure.

The only downside to zippers is that they tend to expose the baby’s trunk during a diaper change, since most zippers start at the top. In this case, I recommend you simply put a blanket on their tummy to help them maintain a cozy body temperature as you change them.

Swaddles:  I found the pre-formed ones with zippers or velcro (such as Summer Infant SwaddleMe, Halo Sleep Sack or the Woombie) to be by far the easiest to close and open. As with other clothing items, consider the stretchiness of the material as you select a swaddle.

One of our cute velcro bibs.

One of our cute velcro bibs.

Bibs: Consider using bibs with Velcro rather than snaps for as long as possible as Velcro produces less direct strain to your thumb joints. Once the baby starts ripping off the bib, you might have to change to snaps as they tend to be harder for babies to take off. We really like the Tommy Tippee Velcro bibs and the Zippy bandana bibs, which have relatively easy snaps.

One piece outfits versus 2+ piece outfits: I’ve definitely come to prefer one piece outfits (usually marketed as “pajamas”), as they require you to put on just one item of clothing and many come with zippers. However, it might be easier to put two loose/stretchy items onto a squirmy baby, so I recommend doing some trial and error with your babe and seeing which is easiest.

Additional tips: I would recommend minimizing the total amount of clothing changes you attempt/do in a day. Does your child really understand or care about the concept of “daytime” clothes versus “pajamas?” Unless there is a temperature, cleanliness or safety related reason for them to wear a separate outfit, I avoid changing just for the sake of it being a certain time of day. The exception is safety related to sleep: as mentioned earlier, it is not recommended for babies to sleep in hats, hoodies or other loose clothing, for the same reason it’s not recommended to sleep with blankets – there’s a risk of entrapment and thus suffocation. My overall recommendation is to conserve your energy and joint expenditure and minimize clothing changes when possible, as long as that is safe for baby!

Diapering & Changing stations

Since you will be changing 10-15 diapers a day in the early days, it’s important to consider how easy the diaper is to put on and take off and the ergonomics of where and how you will be changing them.

Diaper's on, mama, time to play now!

Diaper’s on, mama, time to play now!

1) Diaper Characteristics: Your main options are cloth diapers versus disposable. I don’t have any personal experience with cloth diapers, but I know that they come in two main options: snap versus Velcro. This post provides a comprehensive overview of the two options, and you might not be surprised after reading the clothing section that Velcro is reported to be the easiest on the joints (however it is less durable).

Most disposable diapers have similar closures that are as easy as Velcro, but you might want to try a few brands to see what is easiest on your body. I have used Pampers and Huggies with similar ease, and found the Honest Company brand diapers to provide slightly more resistance and thus require a little more force/strain on the fingers than Pampers or Huggies.  The same concept of “stretchiness” from above applies: the stretchier the diaper material, the easier it is to stretch the closure around the baby’s body and thus less force required on your joints when you are going to change them.

2) Set-up of changing area & body mechanics: I encourage you to consider the ergonomics of your changing area(s). Your main options are: buy a special changing table, use the changing table extension on a crib item such as the Pack ‘N Play, and/or use a travel changing pad on whatever surface is nearest you (such as a counter, couch or floor).

You don’t want to have to bend down too far to reach the baby – image credit to

Regardless of what you choose, it’s generally advised to change the baby on a surface that is slightly below the level of your elbows so that you don’t have to reach up or bend down excessively (which can cause strain on the back and/or knees). This article provides a nice overview of how to set up a changing table, and I will echo their suggestion that you make sure all your important items are nearby (wipes, clean diaper, cream, hand sanitizer, etc) so you won’t be tempted to leave the baby to grab something quickly and you can avoid excessive bending/lifting/carrying of items.

3) Location of changing area: As mentioned in my previous post on caring for the caregiver in the early days, consider having multiple diaper changing areas so that one is convenient to you. This allows you to save energy and minimizes the distance you have to carry the baby; little changes can add up quickly, especially if you are experiencing pain and inflammation.

Feeding related items

Yes, babies mostly “eat, sleep and poop” in the early days, so we’re covering these items first! Your main options for feeding in the first 6 months are breastfeeding, bottle feeding, or “combo feeding,” which involves a combination of breast and bottle feeding. This area is hugely complex, and I am just going to focus on areas that are specifically relevant to protecting tender joints and preventing repetitive stress injuries.

I have a pillow under my right arm here and am attempting to keep my left hand in a neutral position to minimize strain on my body while feeding Charlie.

I have a pillow under my right arm here and am attempting to keep my left hand in a neutral position to minimize strain on my body while feeding Charlie.

 1) Body mechanics: Whether breast or bottle feeding, be aware of your body position and try to assume positions that result in the least amount of stress/strain on your body. This sounds obvious, but trust me, for many people getting the hang of feeding will require an intense amount of focus on the baby and it will be easy to forget to protect yourself during this process. This article provides a fabulous and comprehensive set of instructions for the ergonomics of feeding and includes some really great pictures, so I encourage you to check it out.

Being aware of proper body mechanics while feeding is very important because you will typically be feeding at least 8 times a day during the first 3 months, usually down to 5-6 by 4-5 months. Most people use pillows such as the Boppy or My Breast Friend whether bottle or breastfeeding, as the pillows support the baby’s body weight and thus minimize potential shoulder strain. Also consider your wrist position as you hold the bottle, breast or baby; it’s best to avoid extreme or awkward angles. Take care to remain as upright as possible, rather than slumping downward towards the baby (easier said than done!).

2) Breastfeeding specific items:       

Me in one of my many robes, which I found super useful while breastfeeding.

Me in one of my many robes, which I found super useful while breastfeeding.

 Clothing items: Consider avoiding “nursing tanks” or bras if possible, as these often require weird/awkward wrist and finger positions to get them on and off, from my experience. I found it easiest to live in simple loose robes for the first 8-10 weeks of Charlie’s life. If you do need to use special nursing bras, tanks and other clothes, be sure to test out the closures beforehand to make sure they are as easy to open and close as possible.

 Breast pumping: I highly recommend getting a bra that allows you to be “hands free” to minimize stress on finger joints and awkward wrist angles required to hold the bottles otherwise. As a  bonus, most of these bras zip up the front, which is easier on the shoulder joints than “regular” bras which typically are secured in the back!

3) Bottle feeding: Your decisions around what bottle type to choose will likely be affected by your baby’s specific preference in addition to what is easiest on your joints. Most people have to try a lot of different brands before finding a good fit, so be patient during this process!  I recommend considering the following as you select a bottle type/brand in order to minimize stress on the joints:

    • Bottle parts everywhere!

      Bottle parts everywhere!

      How many little parts are there, and how easy are the parts to put together/take off? These two are related, as you can probably deal with a brand with lots of little parts as long as they are easy to put together/take apart.  I only have experience with the Dr. Brown’s brand, and most of the parts are easy with the exception of the vent tube (cylindrical shaped object) and vent insert (or as my husband and I call it, the “white thing”). I would recommend testing out friends’ bottles and brands before making a choice!

    • How will you clean the bottle parts? Since most bottles have lots of little parts, cleaning them can be a big job. I found the medical advice on how to wash/sterilize bottles to be confusing, and I encourage you to ask your pediatrician or nurse if you have questions. Your general options are to wash by hand or in the dishwasher, the latter of which is obviously easier on the joints! To sterilize parts, you can boil the parts or purchase a microwave steam bag, both of which are relatively easy on the joints.
    • Ready to feed formula bottle option: If you are formula feeding it is recommended to use “ready to feed” bottles for the early days (again, precisely how that is defined varies depending on whom you ask). These bottles are by far the easiest on your joints as they come pre-mixed and assembled, however they are also the most expensive by a very wide margin as compared to powdered or liquid formula.

Movement items: Baby Carriers, Strollers, Car Seats

8 carrier

Things I love that are captured in this photo: 1) my baby, 2) my Moby wrap, 3) CHOCOLATE.

1) Baby carriers. Baby carriers are a great way to minimize stress on the hand joints…once you have them on! When designed and fitted correctly, carriers can keep the baby close to the center of your body so the baby’s weight is distributed and supported by your large joints rather than your small wrist/hand joints when you are carrying them.

There are many different resources to help you decide on the best and safest carrier(s) for you and your baby, and most major cities have “Baby wearing” groups where volunteers let you try on different carriers and help you decide between the overwhelming options. I am not an expert in this area, but from my experience I will highlight aspects of baby carriers that are particularly relevant for people with arthritis or related joint issues. I recommend considering the following as you decide on a carrier:

    • How easy it is to take on and off? Specific items to consider include:
        1. The Pikolo has nice adjustment straps on both sides.

          The Pikolo has nice adjustment straps on both sides.

          Closures and adjustment mechanisms: Does the carrier require lots of pinching or pulling in order to secure or tighten it? If you have thumb pain (as I do), this is particularly important as many of the closures require pinching with the thumb joint. Are the straps easy to tighten and loosen? Are they located on both sides or just one side? For example, I like that the Pikkolo has strap adjustment areas on the left and right side of the bottom part of the carrier (as opposed to the Ergo, which has just one), so that I can choose to tighten/loosen the side with the hand that is experiencing the least pain in the moment. A general principle of joint protection which I alluded to earlier is that you want to spread the force across multiple joints rather than requiring one joint to absorb all the force for an action (and on a related note, for the kind of arthritis I have that affects the small hand joints most, you want the force to be absorbed by bigger joints when possible).

        2. The K'Tan is conceptually easy but since it's tighter fitting, it caused more stress on my joints than the Moby.

          The K’Tan is conceptually easy but since it’s tighter fitting, it caused more stress on my joints than the Moby.

          Resistance the material provides as you put it on or have to put baby in it: Soft carriers such as the Moby and K’Tan are really comfortable for the baby, but they differ in how much force is required to put them on. For example: the K’Tan eliminates the sometimes confusing process of getting the wrap onto your body, but since it is “fitted” to your body size (it comes in specific sizes as opposed to the one size fits all Moby), I found it required more force to open the fabric wide enough to get the baby in than the Ergo or Moby.

        3. How does this product support the baby’s weight so that you don’t have a lot of stress on your back or other tender areas? In my personal experience, the carriers that require closures such as the Ergo and Pikolo seem to distribute the weight of a heavier baby a lot better than soft carriers such as the Moby. Again, a lot will depend on your own body mechanics and the size/shape of your little one.
        4. The Ergo fits myself and my husband equally well!

          The Ergo fits myself and my husband equally well!

          Versatility of wearer: can this item be used easily by a partner/friend so they can take some of the load off you (literally)? The Ergo and Moby were great in this regard, and the K’Tan is not as versatile in this way.

        5. General advice: I recommend having a few different carriers or using one carrier with a few different “holds” so that you don’t cause repetitive stress on one area of your body. Look at your carrier’s guidelines for what ages / stages are linked to different holds; it can be confusing because keep in mind that babies reach stages at different ages.

2) Car seats: I highly recommend you utilize resources such as The Car Seat Lady as you make a car seat decision. The main items relevant to protecting the caregiver’s joints are as follows: seat weight, buckles/closures/straps (how easy are they to secure and tighten/loosen), seat design (infant versus convertible), and how easy it is to put in and take out of the car.

        • My husband holds the Chicco infant car seat with ease on Charlie's first day home.

          My husband holds the Chicco infant car seat with ease on Charlie’s first day home.

          How heavy is the car seat? Weight is important if you are using an infant seat and plan on taking the baby in/out of the car while in the seat, but it may not be as important when you get to the convertible or booster stage when you will likely not be moving the seat in and out of the car as often. I used the Chicco Key Fit 30 infant seat, which is one of the lightest yet safest options, and we really loved it – no complaints at all! I “hooked” it in my elbow and tucked my elbow close to my body when I carried it, which helped minimize strain on my hands.

        • How easy it is to put the car seat into and out of the car? You will want to try this yourself because the ease will depend on your specific issues and the size/shape of your car and the seat in question. Regardless of your car set-up, remember to follow basic joint protection strategies and carry the car seat close to your body with your larger joints as much as possible, to minimize stress on your fingers.
        • Most car seats have 2 kinds of buckles (one near the pelvis, in red here, and one on the chest, in black). They are tightened/loosened by simultaneously pulling on the thing at the end (past the orange blob) and pulling on the straps (in gray).

          Most car seats have 2 kinds of buckles (one near the pelvis, in red here, and one on the chest, in black). They are loosened by simultaneously pulling on the gray strap near baby’s foot(past the orange blob) and pulling on the straps (in gray), and tightened by pulling just on the gray strap at the bottom (phew!).

          How easy is it to tighten/loosen harness/straps? Keep in mind that this will be important as you will be loosening the straps every time you get the child out of the car, and tightening them each time you put them into the car seat. In most car seats, you tighten the harness by pulling up on a strap at the bottom, which can definitely be hard on the hand joints.

        • How easy are the buckles to clasp and unclasp? Unfortunately for caregivers with tender joints, car seat buckles seem to be difficult to manipulate as they have to be resistant enough to prevent a child from successfully unbuckling themselves. Again, be sure to try this aspect before you purchase a seat. I found our infant buckles were way easier on my thumbs than our convertible seat’s buckles.

3) Strollers

Strollers vary widely in weight, ease of pushing, ease of folding up/securing, ease of getting baby in and out and resistance/ease of closures. The the same concepts from baby carriers and car seats apply to strollers regarding harness straps and buckles. In addition, I found it important to consider:

        • Gabe rocks the lightweight Snap 'N Go.

          Gabe rocks the lightweight Snap ‘N Go.

          How easy is the stroller to fold and unfold? I have a Snap ‘N Go (which only works for my infant car seat), BOB Revolution for working out and longer/bumpier walks and the City Mini Baby Jogger (which specifically states in it’s instruction manual that it is NOT a jogging stroller!) for shorter trips.  They both fold super easily (video for City Mini here, and BOB Revloution here), but the City Mini is much lighter and more compact and thus easier to put in and take out of the car.

        • How easy it is to put the baby in and out of safely? The same buckle/strap issues apply from the car seat section. In terms of initially getting the baby in and out of the stroller, however, strollers allow more wiggle room than car seats. With a car seat you have to work within the confines of the relatively small door opening, whereas with a stroller you can move your body around either side of the stroller or stand directly in front of it to put the baby in comfortably, depending on how you are feeling.
        • The BOB Revolution is great for uneven surfaces and even works on sandy beaches!

          The BOB Revolution is great for uneven surfaces and even works on sandy beaches!

          How easy is it to push over the types of terrain you expect to traverse? Here’s a classic example of a tradeoff; the BOB is heavy to lift and put into and out of the car, but it is extremely light and easy to push over a wide variety of terrains. The Snap ‘N Go is extremely light and easy to fold/unfold and put into and out of the car, however it requires more force/stress on the hand joints to push, particularly over any terrain that is not entirely flat. So, keep that in mind as you make stroller decisions!

        • General recommendation: Remember to pay attention to your body mechanics as you fold/unfold and put the stroller into and out of various places (“lift with the legs, not the arms!” and keep the stroller close to your body).  Think about “activity conservation” and try to minimize the amount of times you have to take the stroller into and out of places; for example, I try to really consolidate my errands and social activities so I’m not constantly battling the stroller and car seat.

Cribs, bassinets and other sleep items

The baby will be sleeping a lot in the early days, and it is advised to practice good body mechanics as you lift baby into and out of the crib in order to avoid excess stress on your body. In the early days I found it useful to utilize portable cribs, however once our baby could roll over and sit up independently, options became more limited and we ended up using the crib almost exclusively (although he does still take some naps on me in the Ergo baby carrier, which is like a wonderful, heavy, warm hug!). I recommend that you consider the following:

Charlie in his 4 in one crib, which has a higher setting for infants, lower setting for standers, and can be used as a toddler and big kid bed.

Charlie in his 4 in one crib, which has a higher setting for infants, lower setting for standers, and can be used as a toddler and big kid bed.

For immobile cribs: Does it have a higher up option for infants? This is really helpful for the early days to prevent excessive lifting/bending. Since “drop down cribs” have been ruled unsafe for babies, you will have to do some level of bending in order to get the baby in and out, but the higher up infant setting minimizes the amount of bending down you have to do. Most cribs marketed as “4 in 1” will have that option.

For portable cribs: There are 3 elements to consider for your joint protection when it comes to portable cribs: how easy are they to fold up and take down, how easy are they to transport, and how easy are they to place the child into and out of?

Charlie snoozes in the flat Rock 'N Play.

Charlie snoozes in the flat Rock ‘N Play.

Some of the folding ones such as the Rock ‘N Play portable bassinet place the baby higher up than others and thus require less bending when you put them in and lift them out, which is a nice bonus.

There are also semi-portable options such as the “Arm’s Reach Co-Sleeper” which can be really helpful as it attaches to your bed so that you theoretically can just roll over and attend to the baby’s needs rather than having to get up and then bend down and pick up the baby, yet it keeps baby away from potentially unsafe hazards such as soft bedding and blankets.

Final recommendation: Seek help if you are in pain

If you feel a degree of pain that prevents you from performing basic or essential tasks to care for your child, seek help from a medical professional! On a few parenting message boards/Facebook groups, I’ve heard stories from mothers who have waited too long to get help because they were embarrassed or felt silly for feeling pain over something “so basic” as caring for a child. Please know that caring for a child is a very physical job, and medical professionals can provide many options for minimizing current pain and prevent future pain.

My hard splint made of thermoplastic helps keep my wrist and thumb protected as I lift and carry Charlie.

My hard splint made of thermoplastic helps keep my wrist and thumb protected as I lift and carry Charlie.

For example, I have a total of 4 splints to address wrist and thumb pain from caring for Charlie and my job as a pediatric occupational therapist; they hold my wrist and thumbs in place to help as I pick him up and put him down. The harder splints really help support Charlie’s weight and I’m so glad I was proactive in getting a referral to a Certified Hand Therapist before the pain progressed further. Splinting can help support your joints and minimize additional pain and inflammation from performing daily activities.


In conclusion, I simply recommend that when selecting baby items, you consider the stress the items may cause on your body. Preparing for a baby can be very overwhelming, and it’s easy to focus so much on the baby that you forget to consider what might be best or most appropriate for the caregiver. Long term, the baby will be best served by a caregiver who can use their body to the maximum of it’s potential, so you’re doing both your baby and yourself a favor by protecting your joints!

19 holding charlie

Here, I am holding charlie in a way that minimizes stress to my small hand joints; his bottom rests on my right forearm and I am securing him to my chest with my left forearm with my thumb close to my pointer finger.

20 holding charle

In this picture I’m holding Charlie in a way that causes much more stress on my thumb and small hand joints than in the picture on the left. This hold is definitely not ideal, although at times it’s hard to resist!

 On a final note, while it’s super fun to discuss and list what products to buy, please keep in mind that the way in which you interact with the items will likely play the largest role in how you are able to minimize joint pain and prevent repetitive stress injuries.

There are many more items I did not cover, for fear this post would become even longer and more unweildy. These items include: bathing related items, toys, and older baby feeding items such as high chairs, spoons, cups, etc. However, as you’ve seen, the same principles apply across a wide variety of items. Please let me know if you have any additional thoughts/recommendations in the comments section, especially those with joint pain (either chronic or caused by repetitive stress during child rearing)! Do you have any additional tips/suggestions? Let me know in the comments section!

*The information contained on this blog should not be used as a substitute for the medical care and advice of your doctor and your child’s pediatrician.

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