Pediatric Conditions Presentation PDF

PEDIATRIC CONDITIONS Krista Bulow MSc Pht.  WHEN WORKING WITH CHILDREN WE HAVE TO BE AWARE OF THEIR GROWTH SPURTS BONES GROW FASTER THAN MUSCLES CAN ACCOMMODATE AT TIMES, THEREFORE GROWING PAINS IS A REAL PHENOMENON THAT WE NEED TO EDUCATE ABOUT Osgood Schlatters ...

PEDIATRIC CONDITIONS Krista Bulow MSc Pht.  WHEN WORKING WITH CHILDREN WE HAVE TO BE AWARE OF THEIR GROWTH SPURTS BONES GROW FASTER THAN MUSCLES CAN ACCOMMODATE AT TIMES, THEREFORE GROWING PAINS IS A REAL PHENOMENON THAT WE NEED TO EDUCATE ABOUT Osgood Schlatters  OSGOOD SCHLATTERS Due to repetitive traction and pulling on the tibial tubercle leading to irritation of the growth plate. Because of this, the tibial tubercles' bony prominence becomes inflamed and even more pronounced. Painful symptoms are brought on by running, jumping, kneeling and sport related activity. Symptoms include Knee pain and tenderness on palpation of the tibial tubercle Swelling at the tibial tubercle Decreased flexibility of the Quads and hamstrings.  MANAGEMENT Focus on reducing pain and swelling If child is limping and experiencing large amounts of pain, limitation of activity and sports may be needed for a short period of time. The pain may remain to a certain level until the growth plate closes. Important to know that continued activity will not cause long term damage, you just want to limit the discomfort in the moment Intervention Stretching of the quads and Hamstring daily NSAIDS for pain and swelling Icing for 20 minutes at a time to reduce swelling Patellar tendon taping or strap. Most symptoms will disappear once a child completes their growth spurt/puberty The prominence of the tubercle will remain once puberty is completed.  Legg-Calvé Perthes (LCP) Disease  PATHOPHYSIOLOGY A non-inflammatory, self-limiting disease*, in which the femoral head becomes flattened at its weight-bearing surface secondary to avascular necrosis. Affects children between the ages of 4 and 8 mainly but can range from 2 12 years of age. More prevalent in the male sexe. Cause: unknown * An illness or condition which will either resolve on its own or which has no long-term harmful effect on a person’s health. LEGG-CALVÉ PERTHES DISEASE PATHOPHYSIOLOGY  LEGG-CALVÉ PERTHES DISEASE IMPAIRMENTS The disease occurs in 4 stages: 1. Avascular necrosis 2. Fragmentation of bone 3. Re-ossification (new bone grows) 4. Healing (new bone reshapes) Although this is a self-limiting disease, permanent deformity of the femoral head may result, which increases the risk of developing osteoarthritis (OA) over time.  LEGG-CALVÉ PERTHES DISEASE IMPAIRMENTS (hip abd + IR) https://www.verywellhealth.com/perthes-disease-4174322  LEGG-CALVÉ PERTHES DISEASE CONSERVATIVE MANAGEMENT If the disease is not deemed severe: there may be nonsurgical treatments that a child can undergo to overcome symptoms: Monitor progression Crutches to reduce the pain felt when placing weight on the leg, limit high impact activities ROM exercises: help get the leg moving properly again The muscles and ligaments around joint may shorten: Stretching exercises (adductors) Casts, traction or braces may be used to repair any breakages and  LEGG-CALVÉ PERTHES DISEASE SURGICAL MANAGEMENT If nonsurgical treatment options have not been successful, surgery may be required to repair the joint. In this case, there are two common types of surgery: Osteotomy To redirect the femoral head back into the acetabulum. Tenotomy When a muscle becomes atrophied, it is shortened and unable to grow to its natural length at the same pace as the rest of the child’s body grows. When this happens, tenotomy surgery is performed to release the atrophied muscle. The child is then put into a cast to allow the muscle to grow as normal and return to the size it was intended to be.  Slipped Capital Femoral Epiphysis (SCFE)  SLIPPED CAP FEMORAL EPIPHYSIS Fracture through the growth plate PATHOPHYSIOLOGY results in slippage of the overlying end of the femur. Often occurs in obese adolescent males Bilateral 20-40% of time Groin pain, but may cause pain in only the thigh or knee Gait with limb in external rotation Need surgery ASAP - hip pinning NWB until surgery  SLIPPED CAP. FEMORAL EPIPHYSIS DATA COLLECTION & TREATMENT Refer to management of hip fracture. What data collection and treatment would you suggest that a physio. tech. implement for a 12 year-old patient who presents 4 weeks s/p (R) hip pinning for a SCFE with the following information, who is NWB for 2 more weeks? Problem List: Treatment Objectives: Decrease (P) Pain Increase ROM (R) hip Decreased ROM (R) hip Increase strength (R) Decreased strength (R) hip hip Improve gait pattern as Altered gait pattern: NWB (R) w/ A/C indicated x2 IF ANY CHILD PRESENTS WITH PAIN IN HIP AND A LIMP FOR NO NOTED MOI, THEY NEED TO RULE OUT SCFE Torticollis and Plagiocephaly  CONGENITAL TORTICOLLIS Contracture of the SCM muscle that causes an ipsilateral tilt/SF and contralateral rotation of the head Can be due to positioning in Utero and trauma during birth Can be due to positioning of the child in their environment post birth and the child favoring one side when sleeping and playing.  PT MANAGEMENT Education +++ Stretching +++ Strengthening the antagonist muscle Use of the righting reaction when being held and leaning over to one side. Gross motor stimulation Use of toys with sounds and lights to stimulate the correct positioning Focus of Symmetry  PLAGIOCEPHALY Asymmetrical flattening of the skull Can be due to Positioning in utero Torticollis Positioning of baby in the supine position Research has shown that it has no effect on brain development  PLAGIOCEPHALY Management Education+++ Positioning in crib, when being held and when playing Gross motor stimulation Encouraging tummy time Helmet as needed. Slowly helps to remove stress on the parts of the skull that are flattened Spina Bifida  SPINA BIFIDA Neural tube defect The neural rube is the structure in a developing embryo that later become the baby’s brain and spinal cord. Incomplete formation of the spine and spinal cord in utero failure to form around 28 days of gestation) It can range from being mild to causing serious disabilities. Paralysis/weakness and sensory changes distal to the level of defect. UMN spasticity proximal to the level of the lesion Urinary and fecal incontinence. Potential secondary contractures and deformities Possible hydrocephalus (water on the brain requiring a shunt  3 TYPES OF SPINA BIFIDA Spina bifida occulta (occulta= hiden) Mildest and most common form Result of a small separation in one of the vertebrae Many people might not even know they have it Myelomeningocele Most common type (open spina bifida) Spinal canal is open along several vertebra in the lower/middle back Part of the spinal cord, its protective covering and spinal nerves push through this opening. This makes the baby prone to infections The most serious type of spina bifida. Meningocele Rare form where the sac of spinal fluid bulges through an opening in the spine but the nerves and spinal cord remain intact.  SPINA BIFIDA MANAGEMENT Empower the patients Encourage achievement of developmental milestones Verticalization is possible Strengthen remaining muscle groups AROM and PROM Treatment of orthopedic complications: scoliosis, club feet, dislocation of the hip, muscle contractures. Prevention of contractures Minimize deformities Prepare for transition to adulthood. If child had hydrocephalus a shunt may have been placed to help drain the fluid. Cerebral Palsy  CEREBRAL PALSY Injury to the developing brain; Occurs before, during or after birth Causes include pre-term birth, head injuries (shaken baby syndrome), inflection to the brain and spinal cord, obstructed oxygen flow to the brain, pediatric stroke, and malnutrition Patients can have neurological and musculoskeletal problems that affect posture, sensory perceptions, communication and other functions. Symptoms are usually first noticed in infants and toddlers ½ of the children with CP develop hypertonia and spasticity Huge variety of presentations based on the severity of the condition Spasticity Hypertonia Dystonia Ataxia Athetosis Babies with CP are slow to reach developmental milestone and children with CP will show signs of motor delay usually before the age of 2.  TYPES OF CP Spastic diplegia involves the legs more than the arms. Most likely to affect pre-term babies Affects ambulation depending on severity Spastic quadriplegia involves all 4 limbs more or less equally More functional difficulties Spastic hemiplegia involves one side of the body. May be due to a pediatric stroke.  TREATMENT FOR CP Baclofen Muscle relaxant either taken by mouth of directly in the CSF in the spine through a pump placed in the abdomen Therapeutic Electrical Stimulation (TES) Electrical stimulation that increases blood flow to weakened muscles Selective Dorsal Rhizotomy Surgical procedure that involves cutting some of the lumbar and sacral sensory nerve fibers. This operation may help to reduce spasticity Botox injections into spastic muscles to help decrease spasticity.  CEREBRAL PALSY MANAGEMENT Gross motor training Strengthening the muscle to help with function Prevent and minimize contracture Potential need for surgery Rhizotomy and tendon release to help with spasticity Support for Family is important during these times Ambulation training and verticalization when possible Proper use of bracing and gait aids to improve levels of autonomy Scoliosis  SCOLIOSIS Scoliosis is a lateral deviation of the spinal column from the median, usually accompanied by rotation of the vertebrae; Scoliosis can take many forms, in terms of angle of deviation and of indications and symptoms, therefore familiarity with its many associated parameters is necessary for proper understanding of the disorder.  SCOLIOSIS Direction: C-shape S-shape  C-SHAPE SCOLIOSIS characterized by a curvature of the spinal column to one side. The deviation may Left curve = be centered in one Convexity area to the left The designation of the “C” disorder as right or left always refers to the side of the curvature.  C-SHAPE SCOLIOSIS characterized by visible imbalances along the length of the body, certain typical indications should be recognized: Unequal shoulder height: the shoulder on the side with the curvature is higher Unequal distance of the scapulae from the spinal column the scapula on the concave side is closer to the median The inferior angle of the scapula on the concave side is lower Distortion of the rib cage, Which can take several shapes, such as rib hump in cases of rotation in the thoracic vertebrae Imbalance in ilium bone height the ilium ridge on the concave side is higher Unequal distance of arms from the torso the arm on the curved side seems closer to the torso Unequal fat folds in the lumbar and cervical areas fat folds may appear on the concave side.  S-SHAPE SCOLIOSIS Characterized by at least two curves with deviations from both sides of the median line of the spinal column, for example, a superior curvature to the right in the thoracic area, and an inferior curvature to the left in the lumbar area; S-shaped scoliosis usually involves one primary curvature and one additional secondary (compensatory) curvature.  SCOLIOSIS LOCATION The boundaries of scoliosis are determined by the vertebrae that deviate laterally from the median. The disorder may be concentrated in one specific area of the cervical spine (cervical scoliosis), the thoracic spine (thoracic scoliosis) or in the lumbar area (lumbar scoliosis), o; it may implicate many vertebrae in several regions and in different variations. Precise delineation regarding the boundaries of the scoliosis is possible only by means of X-ray.  SCOLIOSIS ANGLES The larger the scoliosis angle, the more severe the disorder; COBB angle (X-ray) a. Defining the boundaries of scoliosis – a line is drawn parallel to the upper part of the vertebra with the greatest deviation (line A in Fig.). b. Similarly, another line is then drawn parallel to the vertebra located at the lower boundary of the scoliosis (line B in Fig.). c. A vertical line is drawn from each of these lines. The angle that is formed at the meeting of these lines – defined as the “angle of scoliosis” – represents the degree of severity of scoliosis (angle "alpha” ). *** Scoliosis angle is important both for diagnostic purposes and for monitoring progression of the disorder.  SCOLIOSIS – VERTEBRAE ROTATION Usually, rotation occurs in the thoracic vertebrae, and is denoted by a protuberance of the ribs on one side of the upper back when bending forward  CLASSIFICATION: FUNCTIONAL SCOLIOSIS Definition Criteria refers to a disorder in which there When lying on the back, the are no structural changes in the scoliosis disappears skeletal system (spinal vertebrae) In forward bending, the scoliosis or pathology in ligaments and disappears muscles. A person who is aware of the scoliosis can correct it voliuntarily.  FUNCTIONAL SCOLIOSIS Possible causes: Incorrect movement patterns that entail asymmetric use of the body in daily activities; Imbalance in antagonistic muscle group strength on either side of the spinal column. Differences in the length of the lower limbs.  PRINCIPLES OF EXERCISE PRESCRIPTION FOR FUNCTIONAL SCOLIOSIS Symmetric exercises should not be used, at least until symmetry is restored. Asymmetrical exercises for lengthening muscles on the concave (shortened) side, and for contracting muscles on the convex (lengthened) side. Asymmetrical exercises are also designed to encourage specific movement of spinal column vertebrae in desired directions.  SCOLIOSIS: STRUCTURAL Structural scoliosis: “three- dimensional spine deformity characterized by lateral and rotational curvature of the spine” disorder involving physical changes in the structure of the skeletal system (spinal vertebrae). In many cases, untreated flexible scoliosis may evolve into a rigid disorder at a higher level of severity.  SCOLIOSIS: STRUCTURAL The following criteria usually indicate structural scoliosiss Rotation in thoracic vertebrae. Such rotation causes asymmetry in the ribs of the thoracic cage and a considerable protuberance of one side of the upper back (rib hump). This protrusion is especially evident while bending forward, and usually appears on the convex side of the spinal column Spinal column deviation from the midline cannot be corrected independently by the patient, and causes functional imbalance in other parts of the body such as the shoulder girdle, lower back or hips.  SCOLIOSIS: STRUCTURAL Classification of Structural Scoliosis: Idiopathic: 70-80% (7:1 female) Congenital (from infancy) Neuromuscular (2º muscular dystrophy, cerebral palsy, etc.) Trauma (ex. fractures)  STRUCTURAL SCOLIOSIS Congenital (from infancy): deformed or incompletely formed vertebra  abnormal loading then accentuates the curve with growth  SCOLIOSIS PATHOPHYSIOLOGY Vertebral bodies rotate to the convexity of the curve and become distorted. In thoracic spine: rotation causes ribs on convex side of curve to push posteriorly, causing a rib “hump” and narrowing of thoracic cage on that convex side. http://girltomom.com/mommy-mistake/rainbows-unicorns- and-perspective/attachment/bex_scoliosis_shotbump-2  STRUCTURAL SCOLIOSIS: IDIOPATHIC Cause: Unknown Genetic component Neuromuscular control mechanisms altered Vestibular system asymmetry/dysfunction Hormonal/biochemical alterations also identified http://www.spinemd.com/operative-treatments/adolescent-scoliosis-correction-reston-va.php  STRUCTURAL SCOLIOSIS: SCREENING & DX Tends to appear in adolescence, usually in girls, also juvenile form (before age 10) Progression and severity depend on skeletal maturity and severity at diagnosis Early dx is key!  STRUCTURAL SCOLIOSIS: DX AND MONITORING “Cobb angle” Measured on x-ray Greatest angle of the curve  SCOLIOSIS TREATMENT: STANDARD OF CARE IN NORTH AMERICA Monitor: “wait and see” Curve 45 or 50º depending on skeletal maturity SOSORT - SOCIETY ON SCOLIOSIS ORTHOPEDIC AND REHABILITATION TREATMENT (HTTP://WWW.SOSORT.MOBI/INDEX.PHP/EN/): goals of conservative treatment (monitoring, bracing, and scoliosis specific exercises) 1. Stop curve progression at puberty (or possibly reduce it?), 2. Prevent or treat respiratory dysfunction, 3. Prevent or treat spinal pain syndromes, 4. Improve aesthetics via postural correction.  SCOLIOSIS: SURGICAL MANAGEMENT - Surgery: spinal fusion  STRUCTURAL SCOLIOSIS: FUNCTIONAL Fitness level often affected, may be low IMPACT ? Poor self-image ? Reluctance to participate in activities while wearing brace d/t impairments in respiratory function or bulk of brace  Children/teens are encouraged to be as physically active as possible  Parent must take an active role in this process. Severe curves: aerobic capacity may be impaired endurance exercises should be prescribed 30 min bike ergometry 4x/wk for 2 months  aerobic capacity ↑  STRUCTURAL SCOLIOSIS: AFTER SKELETAL MATURITY Generally, curvatures less than 30 degrees will not progress after the child is skeletally mature. More severe curves may progress slowly over the years due to abnormal loading (about 1 degree per year) 50 year natural history study: Pain is more common than in the general population but is usually not severe or disabling. Patients generally healthy and lead functional productive lives.  SOURCES https://kidsplus.com/parent-resources/doctors-notes/infant-torticollis-stret ching-techniques/ https://www.londonorthotics.co.uk/loc-blog/2023/apr/bonnies-flat-head-sy ndrome-success-with-the-locband-lite/ https://brownmedpedsresidency.org/plagiocephaly-getting-a-head-of-the-p roblem/ MCKEOGH SPEARING, E. (2023). Tecklins pediatric physical therapy. WOLTERS KLUWER MEDICAL. Pictures: google open source