Pediatric MSK Conditions PDF

Pediatric MSK Conditions Lecture I - **Developmental biomechanics (unique to kids)** is defined as "the **effects of forces on the musculoskeletal system during the entire life span"** ([LeVeau & Bernhardt, 1984](https://fadavispt.mhmedical.com/content.aspx?bookid=3042&sectionid=2547...

Pediatric MSK Conditions Lecture I - **Developmental biomechanics (unique to kids)** is defined as "the **effects of forces on the musculoskeletal system during the entire life span"** ([LeVeau & Bernhardt, 1984](https://fadavispt.mhmedical.com/content.aspx?bookid=3042&sectionid=254793634), p. 1874). Understanding how the musculoskeletal system changes and reacts to internal and external forces provides a framework to evaluate musculoskeletal examination data and develop a plan of care - **Clinical Conditions** affect growth and development of musculoskeletal system directly or indirectly and can adversely affect structure and function (bone, muscle, and connective tissue) - Musculoskeletal and neurologic systems are **intertwined (CP can result in weakness and contractures)** - Therapy is designed to promote **adaptation to prevent or correct musculoskeletal impairments** +-----------------------------------------------------------------------+ | **Muscle Development** | +=======================================================================+ | - Most skeletal muscle fibers present at **birth** and all present | | at **12 months** | | | | | | | | - Pre-term babies vs. full-term babies develop mm. differently | | | | | | | | - Muscle fibers are susceptible to both **internal and external | | influences** | | | | - Muscle cells may not be able to **regenerate** in certain | | conditions | | | | | | | | - Kids with muscular dystrophy can't regenerate | | | | | | | | - Spastic muscles **common impairment** are smaller overall and | | more **susceptible to contractures** | | | | | | | | - Ex: CP- mm. will not grow with the skeletal mm. | | | | - More contractures will affect the length-tension relationship of | | the mm. (lengthened too much) | | | | - Trying to maintain flexibility while they are growing is KEY! | | | | | | | | - Muscles do not keep up with **growing bone** and **sarcomeres | | overstretch** | | | | - Whether atrophy or hypertrophy occurs in Type I and Type II | | muscles in different conditions **inconclusive** | | | | | | | | - Kids with CP don't use Type II mm. fibers as much, which can | | affect posture of the mm. | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Skeletal and Articular Structures** | +=======================================================================+ | - Bone development progresses **most rapidly in the prenatal | | period**. By the time of birth, the **diaphysis** are almost | | ossified. If a child is born **prematurely**, however, | | **osteopenia (soft bone) is frequently seen** | | | | | | | | - NICU PT's will add soft pressure to promote weight into the joint | | with treatment | | | | | | | | - Eventually, the **epiphyseal plate is ossified**, the diaphysis | | and epiphyses are joined, and the growth of the bone in length is | | considered complete. The timing of complete ossification varies | | with each bone. Most bones are **fully ossified by 20 years of | | age** | | | | | | | | - This is why when children have a fx it heals so quickly! | | | | | | | | - The basic structures of the joint are formed during the **sixth | | to seventh weeks of gestation**, but the **final shape** develops | | throughout **early childhood** under **the influence of the | | forces** of movement and compression | | | | | | | | - Ex: BPI patients could have an underdeveloped GH joint due to IR | | position and not full ROM within the shoulder | | | | - Want to promote passive ROM but especially active very early! | | | | | | | | - After initial development, bone shape can be changed through a | | process of **bone functional adaption**, which uses **resorption | | of old or immature bone and formation of new bone** to determine | | its shape. Bone structure **adapts in response to the mechanical | | forces** that are placed on the bones. This when we as therapists | | can influence bone structure | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Bone Growth** | +=======================================================================+ | - Get the most changes in shape of the bone **before puberty!** | | | | - **Poor nutrition** can cause deformities in the bone | | | | **How does it affect function?** - with an assessment you want to | | look at alignment of the joint **(running, jumping, playing)** | | | | **Wolf's Law**: bone forms to the stresses that are placed on it | | | | - **Laxity and low tone can form abnormal alignment**: Foot | | example- too much pressure on the 1st metatarsal can develop | | hallux valgus, and present with pronation along with less bone | | formation on the lateral aspect | | | | | | | | - Can affect balance and ability to jump & run | | | | **Growth & Regulation** | | | | - Ex. issues: leg length discrepancy, CP pts. have spasticity and | | not enough flexibility | | | | | | | | - Mm. causes **excess tension & compression** in an abnormal | | direction (**perpendicular** to bone) on the bone | | | | - **Botox** can improve excess spasticity to promote optimal length | | of the mm. | | | | A diagram shows the structures of the bone. | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **MSK Development in Childhood** | +=======================================================================+ |  | | | | **NICU** | | | | **Pre-mature infant (EXTended posture):** not developed mm. tone, not | | positioned good to push against womb and move | | | | - A preemie patient will need to work on flexion during treatment | | time | | | | A full term infant lies supine, with both elbows flexed and hands on | | either side of the head. The legs are raised, extended to either | | side, and the knees are flexed.**Full-term infant (Physiological | | FLEXion)** WNL: no full EXT of hip and knee, flexible foot but turns | | in | | | | **Primary** Impairment: Spasticity | | | | **Secondary** Impairment: Contractures | | | | - **3-4 months old**: kyphosis WNL, so 8 months with kyphosis not | | WNL and should have good EXT | | | | - **6 months**: should be able to have wrist EXT and not curled | | fingers | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Long-Term Effects of Atypical MSK Development** | +=======================================================================+ | Examples: Muscular dystrophy- may need to be on steroids, kids on | | seizure medication | | | | - Many neurological or **genetic conditions are considered | | non-progressive,** but result in musculoskeletal impairments that | | often **become worse as the child ages (secondary impairments)** | | | | - Adults with CP frequently develop a wide range of musculoskeletal | | issues such as **scoliosis, hip dislocation, cervical neck | | dislocation, contracture, arthritis, patella alta, overuse | | syndrome, nerve entrapment, and fracture** | | | | - Children with CP typically have **delayed walking, ROM | | limitations, and atypical muscular pull/spasticity** | | | | - Hip is unstable at birth, subluxation and dislocation **therefore | | are common problems in children with spastic CP due to loss of | | abduction and extension** | | | | - Pathological conditions of the hip have been increasing such as | | **Legg-Calve'- Perthes (LCP)-decreased blood flow into the joint, | | pain and inflammation** and **Slipped Capital Femoral Epiphysis | | (SCFE)-femur slips or separates at the hip joint** | | | | - Rotational or angular problems are common such as **in-toeing, | | Blount's Disease, patella alta, and others** | | | | - Physical therapist in position not only to help identify these | | disorders and participate in treatment, but to also **educate | | families** about how this will **affect the child now and later | | in life** | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Normal Development of the Femur** | +=======================================================================+ | - The femoral head, neck, and greater trochanteric areas are made | | of pliable cartilage and are attached to the rigid osseous | | diaphysis. As the infant develops, **normal torsional forces** | | about this point of fixation cause a decrease in femoral | | antetorsion | | | | | | | | - Test for hip stability, if unstable will put them in a harness | | \*specifically breeched\*: greater risk for hip dysplasia | | | | - Ex: CP spastic hip flexors causes non-forming acetabulum, femoral | | head= risk for subluxation or dislocation | | | | \*\*Bc they are not actively moving the mm. that surround the joint | | | | - Active external hip rotation and extension forces created during | | walking have a major impact on developmental changes in femoral | | antetorsion | | | | | | | | - Trying to lengthen hip, knee, and ankle joints | | | | | | | | - If active hip motions are minimal or walking is delayed, as is | | frequently observed in children with CP, the infantile femoral | | torsion does not decrease as it should | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Femoral Torsion, Version, and Inclination** | +=======================================================================+ |  | | | | - **Torsion**: Bone is twisted in on femoral head and neck- normal | | with birth, if the mm. don't start pulling into EXT/ABD/ER, you | | will start to develop more torsion | | | | | | | | - Twisting of the bone that causes the foot to "toe-in" | | | | - Flexor contractures with "toe-in" cause greater stresses through | | the hip | | | | | | | | - **Version**: causes the toe to go out (which is worse) | | | | - **Angle Inclination**: when born, there is varus and as they | | develop it will be valgus positioning | | | | - Starts at 150° and changes to 130° | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Genus Varus in Childhood** | +=======================================================================+ | - If still varus at 2-2 ½ years old refer out! | | | | - Could see problems at the growth plat**e** | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **Ankle and Foot** | +=======================================================================+ | - Generally, the newborn foot is very flexible. Newborn talocrural | | (talus articulation with ankle mortice) joint rests in | | **dorsiflexion** and may have a **plantar flexion limitation | | resulting from intrauterine posture**, particularly during the | | **last 2 to 3 months of gestation** | | | | - Forefoot and rearfoot **rest in inversion** non-weightbearing and | | **eversion in supported weightbearing** | | | | - Gravity begins and active movement effects ankle motion and | | plantar flexion increases quickly first year of life | | | | - Lateral border should be **straight** regardless of weightbearing | | | | | | | | - Metatarsal Adductis: curve in ward "shape like a kidney bean" | | | | | | | | - Typical developing children have **flat feet up to 4-5 years of | | age** | | | | | | | | - **Pes Cavus** | | | | - **Flexible flat foot, just have them wear good shoes** | +-----------------------------------------------------------------------+ **CP**   Lecture II +-----------------------------------------------------------------------+ | MSK Exam | | | | - Consistent and logical sequence | | | | | | | | - Just watch how they move, talk to parents about what they're able | | to do, may be reluctant at 1^st^ | | | | - Older kids: walk, run | | | | - Start 1^st^ with observation | | | | - Observation (how do they move on their own), Hx, Exam, | | Eval/Assessment, ROM strength & balance (special tests) | | | | - May not get it all done in 1^st^ eval, who are they seeing and | | what test have they had administered | | | | | | | | - Detailed history (including **birth history)** | | | | - Restructure as needed due to child's level of participation | | | | - Must have a knowledge of pediatric conditions | | | | | | | | - Ex: spina bifida: focus on how much weakness is in the legs, mm. | | testing in the LE (infants not so easy), try diff ways or diff | | positioning to facilitate movement | | | | - Ex: torticollis: focus on neck & possible developmental delay | | | | | | | | - Understanding of examination procedures appropriate for age and | | condition | | | | - Natural environment if possible | | | | - Keep the child engaged | | | | | | | | - Older kid with CP (harder to test), try more functional | | assessment than standardized testing | | | | - Pain scale: can use facial expression of child | | | | - Pediatric Balance Skill: merged from Berg Balance Scale | | | | | | | | - Family-centered plan of care and goals | | | | | | | | - Some parents don't want their child to have braces | | | | - Take parents views into account, certain things they want the | | child to do | +=======================================================================+ | General Assessment | | | | - Observation-Child observed playing or moving around spontaneously | | or assist as necessary | | | | | | | | - Look for signs of pain with limp/compensations (leg length | | discrepancy, hip issues) | | | | - Ex: low mm. tone in adductors and not good core stability | | | | - Movement quality: ex- supine to prone and push up | | | | - ?'s: active through the day | | | | - Babies: not full hip EXT, problem at 6-7 mths old and inhibits | | ROM | | | | | | | | - Range of motion- Assess for limitations, contractures, or | | excessive motion | | | | - Strength-Can estimate strength from skills a child can perform | | such as riding a tricycle, getting up from the floor with half | | kneel, pull to sit, lifting head in prone, climbing stairs or | | others. May use dynamometer at 3 or 4 years of age or manual | | muscle test | +-----------------------------------------------------------------------+ | Disorders Affecting Bone Health | | | | - Normal postnatal development depends on upright posture and | | subsequent stress on the bone | | | | | | | | - Pre-natally: developing structure of bone and jts. | | | | - Ex: decreased uterine growth restriction, no proper stresses on | | bone | | | | - "Club foot" | | | | | | | | - In kids with JIA (arthritis), CP- spastic mm pull jts, lower | | extremity rotation abnormalities are common in ambulatory | | children with JIA or CP and dramatically increase the force | | across the knee. Children with JIA (juvenile idiopathic | | arthritis) typically externally rotate their legs into a position | | of greater comfort. Children with CP have increased likelihood of | | rotational malalignment between the femur and tibia (i.e., hip | | internal rotation and out-toeing) as they age | | | | | | | | - JIA: compensate, keep weight off leg and maybe leg length | | discrepancy, ER leg out, not good arch in foot, no develop mm. in | | bone structure (soft tissue affected also) | | | | - JIA does not = inactivity, flare up maybe do less: inflammation | | affects bone/jt in this condition | | | | - CP: ALWAYS look at hip, x-rays are given, ask parents, no abd or | | ext, will be lots of IR, mm is affecting the way bone or jt is | | forming | | | | | | | | - Adverse effects such as delaying of secondary ossification | | centers and bone reabsorption can result from disuse in children | | with severely limited movement such as CP, spina bifida, or | | arthrogryposis and increase **risk of fracture** | | | | - Non ambulatory CP: BONE WILL be tender compared to other, look at | | WB, can't build bone | | | | - Ambulatory: get weight through the bone and adequate pressure to | | help turn over & build | | | | - Earlier the better | | | | - Premies: Osteopenia!!! | | | | - Fractures in kids: Clinical knowledge- ppl move leg to change | | diaper, happens on the long bone | | | | - Seizure meds: keeps bones from forming how they should | | | | - Educate caregiver/nurse on increased risk of fractures with | | certain conditions | | | | - Corticosteroids causes long-term issues in children: | | example-compression fracture (condition: muscular dystrophy), | | don't do end range in FLX or Ext, posture still ok | | | | - Weightbearing promotes bone density and hip modeling in children | | with CP. Standing programs have demonstrated improved bone | | density when standing between 60 and 90 minutes for 5 days per | | week, hip stability when standing for 60 minutes per day and | | lower extremities were positioned between 30° and 60° of | | abduction. Dynamic weight-bearing on treadmill or using gait | | trainer always better | | | | - \^\^\^ At least standing for an hour: not used before, do 10 mins | | to familiarize, ABD legs to get better WB in the bones | | | | - Dynamic WB better than static!- gait trainer is efficient, takes | | steps as early as possible | | | | - Just as weight-bearing is important for postnatal bone health, | | studies have shown that movement is important for prenatal joint | | development in birds and is believed to be important in humans as | | well | | | | | | | | - Stretching is beneficial as well to provide more motion | | | | | | | | - Not enough amniotic fluid can affect growth! | +-----------------------------------------------------------------------+ | Weightbearing with Adaptive Devices | | | | Ue weakness: use board to support | | | | Stand: at least a year! | | | | Easystand Zing | | | | -used for CP, legs in little ABD | | | | Rifton Gait Trainer | | | |  | +-----------------------------------------------------------------------+ | Interventions for MSK Disorders | | | | - Value of Strengthening Exercises in Various Conditions | | | | | | | | - Degenerative disorder: dischan's (progressive disease)- no | | maximal exercise and stress mm. too much (no regeneration) | | maximal concentric exericise= safe | | | | - Encourage rest periods: increases endurance for walking | | | | - Know what type of strengthening to do: look at mm. dystrophy= | | keep them active, more functional activities and aquatics, WB is | | good (no sit ups or push ups) | | | | - Resisted strengthening: maximal, submaximal, no repitations all | | functional to use mm. they use daily (Weight ball, trunk, | | abdominals, & arms)\* KNOW precautions for rotation!\* | | | | | | | | - Botulum Toxin (Botox- function) in Children : kids with CP, helps | | decrease spasticity, keep mm. stretched out and moving, | | underlying spascity- inn. from the mm to nerves | | | | - Cp: muscle relaxants are used too | | | | - \^\^MM: example 10 year old, increased spasticity in hip flexors, | | and a causes her not to sit well, it pulls her hip fwd and rotate | | trunk anteriorly, look at ROM , identify mm. causing issue | | | | - Talk to pediatrician: for which mm. would be best to treat | | | | - Diplegia: hamstrings tighten cause knee crouch, given botox as | | well | | | | - 3 months: kills nerve endings to mm. and won't return, but | | sprouts other mm. nerve endings | | | | - Benefits of Stretching | | | | | | | | - Long stretching: Ex. neurological, less mm. fibers and more | | extracellular fibers which causes adhesions | | | | - Diplegia CP: dynamic splint at night to help further stretch | | (spastic) | | | | - Low mm tone: flex in mm, hyperextend in jts, adaptive tightness | | (calf and hamstrings common), no aggressive stretching if | | instability of the jt, compression at jt to stabilize | | | | | | | | - Hinged AFO: push off will cause calf mm. to stretch and activate | | functionally | | | | - KYPHOTIC posture: use strength and mobility in musculature | | | | - Look up bracing for rotation!!\*\* | | | | - Fixed AFO: stability at ankle but flexible in other jts (knees) | | | | - Supported Standing and Walking: adaptive equipment (know this), | | lots of times improper equipment is given, good relationship with | | DME provider (safe and effective for functionality), posterior | | walker and anterior walker. \*look up\* | +-----------------------------------------------------------------------+ | Disorders Involving Bone | | | | - Fractures in children: diff in children, don't typically break | | bones, more in adolescence, possible clumsiness or bone disorders | | | | - Osteogenesis: spontaneous fractures (balance issues), brittle | | bones, especially if more severe, mild type: still at risk | | | | - Example: brain tumor= chemotherapy causes peripheral nerve | | issues, sensation and vestibular issues | | | | - If low Dietary or calcium intake= could be at risk for fractures | | | | | | | | - Epiphyseal Fractures: fracture of growth plate, is fracture | | through growth plate= longer to heal, type 1 or 2= pretty good | | prognosis for healing and bone growth after | | | | | | | | - Greenstick Fractures: buckle fractures, pretty common, just in | | kids, side you hit is gonna fracture cortex of bone and bend the | | other side, if serious could be a deformity (will get angulation | | of bone) | | | | | | | | - Osteogenesis, can get diagnosed through genetic testing, | | Imperfecta: | | | | - Type 1- mild: sustain fracture not at birth later on, can | | participate in what they need to, don't hinder what they're doing | | and can move around (no impact sports), adolescence and puberty | | can get more fractures, live pretty normal lives with not many | | limitations | | | | Type II: perinatal lethal form- very brittle, not very common | | | | Type III: SEVERE AND PROGRESSIVE, mostly long bones and legs, can | | have fractures in spine, usually have multiple surgeries and put rods | | in the bones to limit excessive angulation in bone along with | | strengthen (no resistive strengthening), stretching and diff | | movements to try walking and WB through bones, depends on t | | | | Type 4: moderately severe- lots of fractures seen at birth, not much | | deformity in the bone | | | | III and IV- most severe!, still up and moving with WB, transfer early | | on, careful with too much stress on the bone, usually do log roll and | | adapt to how they move, III and IV can transfer themselves, work on | | developmental skills and posture, possible bracing, do get infusions- | | bisphosphonates (calcium to help strengthen bone and grow) | | | | PT: know which bones are affected along with laxity in the joints, no | | aggressive stretch but mm. flexibility in diff positions, no | | resistive exercises= puts stress on long bones (picking them up- no | | arms, around the trunk) | | | | Epiphyseal Fractures (Salter Harris Classification | | | | Five diagrams show the classification of fractures occurring on the | | growth plate. | +-----------------------------------------------------------------------+ | Conditions Affecting Muscle | | | | - Muscular Dystrophy- Duchenne Muscular Dystrophy (DMD) is the most | | common muscular dystrophy and is a fatal disease of progressive | | weakness of the skeletal and respiratory muscles | | | | | | | | - Boys have it, women can be carriers (mild symptoms) | | | | - Siblings can get it- genetic, multiple kids can get it in the | | family | | | | - Cardiac/vascular mm also affected= respiratory system | | | | - Recessive- both mom and dad have to be carriers | | | | - Not really Rx, but genetic therapy is in research, usually go to | | speciality clinic (Vanderbilit and Cincinnati have a mm. | | dystrophy clinic), whole medical team involved | | | | - Possible language and talkative abilities can be an issue: no | | regeneration in the neck mm., can get fat deposits and adhesions | | that will cause the cells to die out | | | | - Some can ambulate but will have a delay (clumsy early on) | | | | - 1^st^ sign: 2 years old, delayed walking and clumsiness | | | | - Progress: Sudo hypertrophy: getting more fat deposits, mm will be | | hard with adhesion, CT in fat deposit will bind mm down (calf mm | | looks swollen-1^st^ sign) | | | | - Affects proximal vs distal mm. early on! Have problems getting | | into supine, stand and have hyperlordosis= can't activate trunk | | mm., with progression will affect UE (shoulder and eventually to | | hand) | | | | - Gowers Manuever: sign of Duchanne, send to neurology | | | | - Call pediatrician for a neurological referral and explain to | | parents the concern and mention genetic testing | | | | - Typical gait: waddle-type, up on toes, mm in calf gets tighter | | and tighter, kyphosis and lordosis | | | | - Daily use of steroid treatments: to help prevent breakdown of | | the mm. (for inflammation and cut down degeneration) | | | | - PT: DEPENDS on the stage, example: beginning and ambulatory-let | | him self limit and do what they can, LOTs of stretching (hams and | | calf, hip flexors- they adapt to positioning) lay on tummy and | | stretch, 1^st^ sign of tightness: night splint to help mobility | | in the calf, aquatics and functional exercises to help ROM, | | stabilize at trunk, NO WEIGHT or Resistance (only limb) balance | | is good, maximal concentric or eccentric exercises, resistance | | through water= work on endurance, breathing type exercises and | | easy to do in the pool to work on inspiratory control/force with | | musculature, if toe walking NO AFO, will make it worse, will get | | out of it in school age, encourage as much as possible, but stop | | when exhausted | | | | - Walkers could help with endurance and mobility ( standing as long | | as possible will help a long way) | | | | - Adapt with equipment, no manual chair, power chair to get around | | school! | | | | - Surgery: scoliosis, if it interferes with breathing, oxygen CPAP | | will help, check vitals for aquatics (cardiac and respiratory, | | talk to parents) | | | | - Adapt to home: lifts, ramps, shower chair, hospital bed | | | | - Can see compensation with Trendelenburg: ipsilateral lean to | | stance leg | | | | - All 4's: elbows locked out, because of weak trunk musculature | | Gawer's | | | | - Difficulty with supine to stand; due to | | | | - Falls: | | | | - Can't hop or propel: looks likes bobbing, can't jump on one foot | | at time (balance and coordination issue) | | | | - Stair climbing difficult: 2 foot step pattern and UE support, | | descend easier | | | | - Runs looks like fast walk, scapular winging, hands on knees to | | bend and pick items up, trunk flexion weak extensors, arm swing | | | | - Vector's-mild, Myotonic-more severe but ambulatory, still | | limitations | | | | | | | | - Spinal Muscular Atrophy (SMA)-Group of autosomal recessive | | disorders caused by mutation or deletion of the survival motor | | neuron 1 (SMN1) gene. This genetic disruption is characterized by | | degeneration of the anterior horn cells of the spinal cord, | | muscle atrophy and widespread weakness, and absent deep tendon | | reflexes. Sensation and cognition are not typically impaired. SMA | | occurs in 1 of every 10,000 live births | | | | | | | | - More rare than muscular atrophy | | | | - affects mm. directly, anterior horn cells affected, less | | innervation to mm | | | | - see more hypotone, not good reflexes, age of onset: 4 types, | | sometimes combo | | | | LOOK UP NAMES AND TYPES LATER | | | | - Type 1: acute Werdnig-Hoffmann (most severe) infantile earliest | | onset, rapid demise | | | | | | | | - Usually results In death after 1^st^ couple years, positioning | | can help and keep flexibility, on vent eventually | | | | | | | | - Type II: Dubowitz disease (chronic)- diagnosed by a year or so, | | sit independently, can walk a little, progressive, longer live | | lived, weakness and in a w/c, stand and walk, older= will live in | | adulthood, some progress faster than others (will see in clinic, | | LOSE ABILITY TO WALK) | | | | - III and IV- milder, III- later in adolescence, typically | | lifespan, some limitations maybe AD Kugelberg-Welander | | | | - Adult SMA IV: develops in adulthood, walk in later age, mild | | limitations | | | | - NEW MED RX fairly effect, still studies on it ; Ucerine (orally), | | type I and II, not showing as much as progression before (new | | research)\*\*\* | | | | - SMA- hypotonia with normal cognition, lot of proximal weakness, | | mm tone so low gets scoliosis | | | | - Interventions: early on look at contractures, get them | | functional, mobility, not resistive strength program, work on | | balance and respiratory, sometimes problem with swallowing, | | speech therapy to work on mm. | | | | - Certain contractures: adaptive equipment eventually, power | | wheelchair, robotic arm-feed themselves | | | | | | | | - Idiopathic Toe-Walking-Idiopathic toe walking (ITW) is a | | diagnosis of exclusion. This means that the child walks on his or | | her toes without any known reason or pathology. The toe walking | | can be intermittent or constant. Literature varies on the | | incidence of familial toe walking, with estimates of a genetic | | component ranging between 30% and 42% of children with ITW | | | | | | | | - CP- common, spasticity, not really sure what causes it | | | | - Typically develops: way they always walked, lower mm tone, | | sensory or tactile issues (40% in kids with Autism), still | | walking on toes by 3 it will not spontaneously go away, calf mm | | will eventually tighten up, inserts for tactile/proprioceptive | | input of foot can help | | | | - Can see kids in school system; never got treated (decrease | | balance and coordination) increase pressure in jts, the forefoot, | | fatigued easier cause working harder, bones develop into | | pressure, calcaneus and talus involved with pressure, arch of | | foot tight (adapts to forces and alignment) | | | | - Toe walker= all they have is push off no midstance cause no foot | | flat | | | | - Therapy: sensory input to foot, try to get them to put foot on | | ground themselves, stretch on wedge (calf) walk on incline, | | better DF is what you want | | | | - In other developmental delays: autism very common | | | | - Management: stretching, vestibular and balance | | | | - Child: protocol- ROM 0 or less can't get into neutral, will need | | some type of intervention beyond therapy-tell parents (serial | | casting, bilateral walking cast and gradually stretch mm, stay in | | it for 2-4 weeks and take them out to restretch and eventually be | | in brace | | | | - 0-5 degrees= night splint (bracing)and manual therapy | | | | - 5-10 deg: night stretching (splint), articulating AFOs, good for | | neuro re-education | +-----------------------------------------------------------------------+ | Connective Tissue Disorders | | | | - Ehlers-Danlos Syndrome (EDS) Heterogenous group of disorders (13 | | types) causing hyperextensibility, ligamentous laxity, tissue | | fragility, delayed wound healing, atrophic scarring and bruising | | /bleeding | | | | - PT intervention critical in most common type of (hypermobile type | | EDS) | | | | | | | | - Primary intervention in EDS is PT, interventions based on | | severity to maximize flexibility, strength, and independence with | | precautions as necessary for joint instability | | | | - Juvenile Idiopathic Arthritis (JIA) Previously juvenile | | rheumatoid arthritis, unknown origin occurs before 16 y/o with 7 | | main categories, most common seen by PT are systemic JIA, | | oligoarthritis, some can have vision problems-- less than 4 | | joints, and polyarthritis- 4 or more joints, more severe type | | | | | | | | - Occurs early on: may notice in elementary | | | | - Example: One joint; episodes of flare ups | | | | - Can grow out of less severe types | | | | - Will see swelling, (systemic) problems with heart and lungs, | | symmetrically joint involvement, stiffness in mm around the | | joints can get contractures, back off resistive exercises, | | aquatics are good, nothing with too much pressure into the joint: | | when no acute episodes be as active as possible for bone health, | | mm lengthened | | | | | | | | - Inflammation to joint space and tissue leads to capsule | | hypertrophy, irregular bone growth, and altered growth chronic | | joint instability, osteoporosis and contractures= decreased bone | | formation, too much limitation can cause detoriation in the mm., | | | | - Treatment includes: modalities, strengthening, range of motion, | | postural exercise, endurance exercise joint protection and | | modification of activities. Must modify treatment when there is | | active inflammation | | | | \*\*\*Functionality\*\*\*\*- play on playground | | | | Basic treatment: flexibility, continue strength, active as possible | | during remission | | | | - Hemophilia: lack of clotting proteins. Three most common types | | are A,B, and C, will not see often | | | | | | | | - Early motor functional delays will give them knee pads and | | helmets for protection | | | | - May need infusion- emergency situation! | | | | - PT intervention for range of motion-promote functional skills, | | strength, adaptive aides, and splinting | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | Disorders Involving the Spine | | | | Scoliosis- curvature of spine | | | | - Structural scoliosis: fixed, no flexibility, the way the bone is | | formed | | | | - Nonstructural (functional) Scoliosis: more flexible and caused by | | positioning or muscle imbalance- will need brace and usually has | | low tone | | | | - Reasons: leg length discrepancy (decreased length in femur) due | | to compensation, shoe lift will help | | | | - 10 deg or more is considered scoliosis | | | | !!!MOST COMMON!!! Idiopathic Scoliosis-Infantile \< 3 yr. , juvenile | | (between 3-10 yr, and adolescent between 10 yrs. and skeletal | | maturity) | | | | - More Structural, sometimes it starts as they grow, caused by | | neuromuscular problems | | | | - Adolescent girls: most common in | | | | Treatment-Bracing- usually used more to prevent progression | | (usually/may wear 23 hours a day), exercise, surgery for spinal | | fusion | | | | Typically, will require surgery if Cobb angle\>45 degrees | | | | Kids with CP, spina bifida, down syndrome: check for scoliosis | | | |  | +=======================================================================+ | MSK Examination (Spine) | | | | Adams Test for Scoliosis: bend over, hands between knees, look at fwd | | bend | | | | If can't stand- put on a ball and look at curvature there! | | | | Scoliosis: spasms and back pain, tight hamstrings | | | | - Stretch mm and strengthen the opposite side | | | | - Sometimes C or S- curve: S- primary curve, lumbar curve- | | secondary curve | | | | - Cobb angle: measure vertebrae on x-ray | | | | - Not always lateral, involves rotation: rip hump | | | | - A boy bends forward at the waist, with arms extended toward the | | floor, palms together. | | | |  | +-----------------------------------------------------------------------+ | Scoliosis | | | | - Progressive curve defined sustained increase of 5° or more on two | | consecutive examinations 4- to 6-month intervals | | | | - Main factors that influence the probability of progression in the | | skeletally immature patient | | | | 1. The younger the patient at diagnosis greater chance of | | progression | | | | 2. Double-curve patterns vs. single-curve patterns | | | | 3. Lower the Risser sign (bone maturity) | | | | 4. Curves that are larger at initial presentation | | | | 5. Patient is female | | | | 6. When curves develop before menarche | | | | - Congenital scoliosis curves are caused by anomalous vertebral | | development in utero | +-----------------------------------------------------------------------+ | Other Conditions Affecting the Spine | | | | - A kyphosis is an abnormal posterior convexity of the spine | | | | - A spinal kyphosis occurs as the result of trauma, congenital | | conditions, neuromuscular, post-traumatic (tuberculosis), or | | Scheuermann disease | | | | - Congenital Kyphosis- Anomalies occur later during the | | chondrification and ossification stages of the embryonic period. | | Posterior segmentation and block vertebrae defects have been | | seen. The most frequent defects are multiple hemivertebrae (44%), | | anterior segment defect (32%), and single hemivertebrae (18%). | | Typically requires surgical intervention without surgery likely | | progress to paraplegia or cardiac dysfunction. Posterior spinal | | arthrodesis can be safely completed in patients as young as 6 | | months of age. Bracing is ineffective | | | | - Scheuermann disease is a rigid form of postural kyphosis. It | | often is neglected and develops during childhood and adolescence | | because of poor posture Most common type of kyphosis in the | | adolescent population. Radiographic criteria includes: (1) | | anterior wedging of 5° or more for at least three or more | | contiguous vertebrae, (2) narrowing of the intervertebral disc | | space and (3) kyphosis greater than 45°between vertebral segments | | T5 and T12 coupled with compensatory cervical and/or lumbar | | hyperlordosis, uncorrected on active hyperextension and | | incongruent vertebral endplates with Schmorl nodes | | | | - Hyperlordosis can also occur in certain conditions due to | | weakened abdominals in conditions such as DMD | | | | - Spondylolisthesis-Dysplastic and isthmic are most common types | | seen in the pediatric population. Described by the degree of | | severity as characterized by percentage of slippage. According to | | the Meyerding classification system, grade I is the mildest | | slippage at less than 25%, grade II is 25% to 50% slippage, grade | | III is slippage of 50% to 75%, grade IV is 75% to 100% slippage, | | grade V refers to the ptosis of the cranial vertebra | +-----------------------------------------------------------------------+ | Acquired Leg-Length Discrepancy | | | | - Two general classifications of acquired limb-length discrepancy: | | | | 1. Direct (growth retardation) | | | | 2. Indirect (growth stimulation) | | | | - "Apparent" limb length discrepancies | | | | **Leg Length Inequality General Treatment Guidelines** | | | | ------------------------------------------------------------------- | | --------------- | | **0--2 cm: No treatment.** | | **2--4 cm: Shoe lift.** | | **2--6 cm: Epiphysiodesis, shortening.** | | **6--20 cm: Lengthening that may or may not be combined with other | | procedures.** | | **\>20 cm: Prosthetic fitting.** | | ------------------------------------------------------------------- | | --------------- | +-----------------------------------------------------------------------+ | MSK Lower Extremities | | | | Use of Tape Measure for Leg-length Discrepancy | | | |  | | | | Galeazzi Sign for Leg --Length Discrepancy | | | | A child lays supine, with legs bent at the knees and feet flat on the | | table, side by side. A doctor compares the height of the bent knees. | +-----------------------------------------------------------------------+ | Congenital Limb Deficiency | | | | - Classification | | | | 1. Transverse Deficiency-level at which the limb terminates. | | | | 2. Longitudinal Deficiency-Deficient bones proximal to distal | | | | - Hemimelia- absence or gross shortening of a bone. Fibular | | hemimelia most common. Proximal femoral focal deficiency (PFFD), | | which is shortening to complete absence of the femur (associated | | problems include acetabular dysplasia. | | | | - Treatment Options-Depends on many factors. Limb lengthening, | | epiphysiodesis, amputation, and rotationplasty. | | | | - Upper Extremity Deletions are more common, consider prosthesis at | | 12 to 15 months, may use a prosthesis for certain tasks but | | prefer remaining hand for sensory input. | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+