Physio Through Life Stages Notes: Paediatrics: Week 1: Intro to Paeds – Consent = Need consent from the parent or guardian if under the age of 14 years Person 14 years and older can consent to their own treatment During the normal course of practice it is wise to get verbal consent from both anyway Maturity and the ability to understand the procedure may be the issue rather than age If a parent does not consent to a child’s treatment and the refusal of treatment puts a child at risk, consider a report to community services Be aware of consent issues with blended or separated families Avoid being alone with a child If you are left alone with a child, consider strategies to ensure you are protected. Domains of Development = Gross motor (big movements eg crawling, walking, running) Fine motor (smaller movements eg manipulation of objects, writing, scissors Talking and understanding Diet and feeding Cognitive (how we think & process information) Social (how we interact with others and the world) Engaging with Infants = Emotionally need to be close to the parents Rely on touch, smell, and hearing You will smell strange to the infant They will become fatigued and irritable very quickly Look for non-verbal signs eg eye contact vs looking away Plan the assessment for minimal handling Engaging with Toddlers = Emotional need to be close to the parents (indication of bonding) Will be self-directed & want to explore - - Stranger danger Good techniques include: Distraction Enticement Sabotage Engaging Primary School Children = Talk to the child & explain the session May try to negotiate Consider whether to offer the choice of activity or not Need to get consent from parent and child before touch Risk benefit decisions may be different eg taping Engaging with Adolescents = Able to consent after age 14 years, but still involve parents May be resistant to engaging with the physio Concerns of parents may not be the priority for the patient Consider the social issues raised by treatment or how diagnosis influences identity Consider their interests Play Development – Sensorimotor Play = From 2-4 months to 10-12 months. Infants aim to learn about environment using senses. Functional Play = Playing with objects in ways that are consistent with the object’s typical use Emerges around 5 – 10 months and increases throughout the second year of life Becomes more frequent and generalises to a wider range of objects as cognitive and motor skills mature Important indicators of cognitive development (as well as other domains) Symbolic (pretend) Play = Child uses representative thought Represents one object with another Emerges from the child’s second year Symbolic play should be considered in clinical practice from 18 months Common themes are schemes the child has seen or experienced such as: Family situations Healing Averting threats Develops towards themes that the child has not experienced eg pirates, space Games with rules = Emerge around school age Play becomes based on peer validation Success is determined by comparing their performance with peers Week 2: Ortho Issues in Infants – Physio often have the job of discussing in-depth with parents the treatment, aetiology, and prognosis of these conditions DDH = Developmental Hip Dysplasia Either has dislocated hips, dislocatable hips, subluxable hips, dysplastic hips. Can result from = Abnormal forces on the femoral head changing the direction of compressive force. Abnormally shaped acetabulum allowing increased femoral head movement. Abnormal shape of femoral head. Combination of all. Vicious Cycle = Increased Fem head movement -> misdirected femoral head compressive forces -> Abnormally shaped acetabulum -> repeats Dislocated hip = very abnormal femoral head forces if any at all. Environmental associations = Swaddling with legs straight Disposable nappies Abnormal muscular tone eg CP Risk factors for hip dysplasia = Breech birth Female Oligohydramnios (Decreased amniotic fluid) High birth weight LSCS (Lower segment cesarian section) 1st Born FHx of DDH Screening = What is US? More experienced = more accurate Blinding and multiple tests help With less experienced clinical examiners US more important. 70 – 90% of DDH detected at birth spontaneously resolve Selective vs universal US Diagnosing DDH: - - Clinical Testing Babies State Barlow Test: attempts to dislocate the hip Ortolani Test: Attempts to relocate the hip Tend to use a combination Passive hip abduction Galeazzi Test General active movement Barlow and Ortolani become less reliable with larger and older children Hip abduction and gait assessment become more reliable Radiological Exam US before primary ossification centres appear. X-ray after primary ossification centres appear. Ossification centres appear between 3 and 5 months of age. Treatment: Ideally treat at a stage where it is evident the hip is not going to spontaneously resolve, but treatment is still going to be effective Pavlik harness - Dynamic splint Little risk AVN (avascular neurosis?) Skin Prob’s Femoral Nerve Palsy Use the ‘Human Position’ 90 - 100° flexion 30 - 60° abduction - Not the frog position Dosage opinions vary. Decision depends on patient. Spectrum of treatment Dynamic splinting Rigid Splinting Closed Reduction +/- Traction Open Reduction +/- Traction Foot Issues in Infants: Talipes Equinovarus – Structural vs postural = May look similar but are not the same Postural is thought to be a packaging deformity Postural should be passively correctable No palpable structural deformity Assessment = CAVE C – Cavus; 1st MT is plantarflexed in relation to the calcaneum A – Adductus; Navicular moves medially off the, Calc rotates medially under the talus V – Varus; Calcaneus moves towards the midline of body E – Equinus; Calcaneus is plantarflexed in relation to the tibia - Subtalar and talocrucal components. Additional assessment tool = Pirani Scale Treatment = Ponseti Method - - Treatment phase Weekly casts and manipulation 4 – 6 weeks 70% require tenotomy (tendon division) Maintenance phase Final cast stays of for 3 weeks Orthosis (boot and bar) – 23 hours a day for three months – At night for around 4 years Ponseti success rate around 90% initial correction rate for patients aged between 1 and 3 years of age. Relapses and long-term result have not been well researched. Open joint surgery possible. Success dependent on adherence. Calcaneovalgus – Packaging issue. Most simply need monitoring and stim to medial side of foot +/stretches. If not fully correctable then needs to be screen for other issue e.g., vertical talus, tibial bowing, or neuro issue. Infant Head Issues – Plagiocephaly = shaped to one side; Brachycephaly = flat head; Scaphocephaly = long head Does not affect brain development, and most resolve by 12-18 months. Ant fontanelle closes 12 -18 month; Post fontanelle closes around 3 months Plagiocephaly = Check C/Sp PROM Encourage stim to look to other side Encourage tummy time and sitting practice (depending on age) Encourage side lying Water pillow Helmet therapy if severe and older Brachiocephaly = Check C/Sp PROM Encourage stim to look to both side Encourage tummy time and sitting practice (depending on age) Encourage side lying both sides Water pillow Helmet therapy if severe and older Scaphocephaly = Common in prems Check C/Sp PROM Encourage stim to look to midline Encourage tummy time and sitting practice (depending on age) Avoid side lying Water pillow Helmet therapy if severe and older Torticollis – Result of a tight sternocleidomastoid May have pseudotumour (Increased ICP, “tumour-like”) They tend to rotate away and tilt towards affected side Stretch what you see Stim to look to other side Erb’s Palsy – Paralysis of the arm caused by brachial plexus injury (C5 – T1) because of shoulder dystocia (= difficult birth; shoulder caught on pubic bone). Range of severity – no ongoing issue to severe issues Initial period of pain and flaccidity, then tightening with increasing spasticity into waiter’s tip position. Treatment = - Initial treatment while flaccid and painful Support arm and minimise painful movement Sling in singlet or with tubigrip Once pain settles (if present) start gently daily PROM Later treatment Maintain range Maintain strength & function Post-surgical rehab Ortho Issues in Children and Adolescents: Paeds Subjective Exam – Usual elements of an adult subjective Also includes birth history, developmental milestones, age of onset and clinical course (same/better/worse), family history, sleeping and sitting positions. Child with Intoeing Gait – Foot progression angle; U-shaped throughout lifespan, greatest as infant/toddler and elderly. 3 main causes = Bony Changes (Soft tissue changes = IR tight, ER weak) - Increased femoral anteversion Check alignment of patella Ext Rot greatest in infants; U-shaped throughout lifespan Int Rot greatest in children; N-shaped throughout lifespan Increased tibial torsion Thigh-foot angle; Smallest as infant, greatest as adult, N-shaped. Metatarsus Adductus - Dynamic = Normal at rest, bends when standing. Much harder to fix Knee Alignment – Genu Varus = - Bow-legs Most cases are physiological, and are managed with monitoring and parental reassurance, until at least 10 years of age. Pathological causes include: Blount’s Disease = condition that affects growth plates in knee. Inside of knee slows or stops producing bone, plate in outside of knee is normal. Rickets = the softening and weakening of bones in children, usually because of an extreme and prolonged vitamin D deficiency. Can also be caused by genetic issues. Trauma = e.g. Salter-Harris Fracture (growth plate; multiple types) Be wary of asymmetry A gap of >6cm (Luke reckons 10cm) between the femoral condyles is considered problematic at any age Genu valgus = Knock Knees Most cases are physiological, and are managed with monitoring and parental reassurance, until at least 10 years of age. Pathologic causes include trauma, obesity, and rickets Be wary of asymmetry A gap between medial malleoli of >8cm is considered problematic at any age Paediatric Flat Feet – Reported between 0.6-77.9% of children. 1% of adult pop. = rigid flat fleet (no change on toes). Most flexible flat feet in children are physiological and asymptomatic. Problematic if child is in pain or posture/alignment is affected. Babies and toddlers appear to have flat feet due to their baby fat which disguises their developing arch. Literature suggests stable arch height at about 8 yrs. Note obese kids, Downs Syndrome, hypermobility, Rheumatoid Rigid flat feet need referral for investigation. Active (muscular structures; Arch returns when standing on toes) vs Passive (e.g. bony structures). Assessment = Foot Posture Index 1. 2. 3. 4. 5. 6. Scored from -2 to +2 Neutral feet approx. = 0, pronated = very +ve, supinated very -ve. Talar head palpation Supra and infra lateral malleoli curvature (viewed from behind) Inversion/eversion of calcaneus (view from behind) Bulging in talonavicular joint Congruence of medial longitudinal arc Abduction/adduction of forefoot on rearfoot (view from behind) Treatment = - MLA strengthening exercises +/- stretching Footwear Orthotics? Shown not to help/fix development or boimechanics Only useful to alleviate pain The Limping Child – Location of physical findings of concern Age of the child Irritability – is there pain on weight bearing, active motion or passive motion History of trauma Presence or history of fever Neurological examination Pain that wakes the child at night can be indicative of more serious pathology Transient Synovitis = Relatively common, with a cumulative lifetime risk of 3% Usually seen in children 3-10 years. Peak incidence 5-6 years Usually unilateral. Usually post viral and fully resolves in 7-10 days If persistent, needs imaging and bloods to exclude serious pathology 10% of cases will suffer a recurrence Perthes Disease = Idiopathic avascular necrosis of the hip Occurs in children 3-12, peak incidence is 5-7 Bilateral in only about 10% of cases Male: Female = 4:1 Often present with Trendelenburg gait, restricted IR, and Abd. Management is to keep boys non-weightbearing whilst the disease is active (often about 2.5 years). No strong evidence though. Sever’s Disease = Calcaneal apophysitis Apophysis = secondary ossification centre, fuse in 2nd decade Site of ligament/tendon attachment, weak point of growing skeleton Apophysitis = traction of muscle/tendon on apophysis Age range 6-12 years Bilateral in 2/3 of cases Active children with tight calf muscles are predisposed If not resolving over 2/12, imaging to exclude other pathology is indicated Osgood-Schlatter Disease = - Osteochondritis of the tibial tubercle Generally occurs in children 9-14 years who have undergone a rapid growth spurt Occurs in approximately 20% of adolescents who are active in sport Bilateral in approx. 50% of cases Pain is exacerbated by running, hills, stairs. Relieved by rest Usually a benign and self-limited condition. Symptoms generally resolve once the growth plate is ossified. Usual course is 6-18 months, during which symptoms may wax and wane. Pain at night or related to rest may be indicative of more sinister pathology Treatment = Pain Control Activity continuation with modification or relative rest Stretching quads/hams/calves as appropriate Strengthening quads/hams/calves as appropriate Taping or bracing Education re management of future episodes If pain persists beyond the closure of the growth plate, needs further investigation Slipped femoral capital epiphysis = Displacement of the capital femoral epiphysis from the femoral neck through the growth plate. Incidence between 1/1000 – 1/10 000 Age range is 9-16 years, mean age of presentation is 12 years in girls and 13.5 years in boys, near the time of peak linear growth Bilateral about 50% of the time Main risk factor is obesity Some presentations are atraumatic. Pain increases with activity IR and abduction limited. Often flexion as well. Adduction usually normal Imaging usually required to differentiate from Perthes or late DDH Usually surgically managed Risk of vascular necrosis ACL injuries = Rupture or disruption of the anterior cruciate ligament. Young Australians undergoing knee reconstruction has risen more than 70% since 2000. The greatest increase is among children aged between 5 and 14. Surgery in boys is up 7.7% and girls by 8.8%. This is possibly due to; to increasing pressure in kids sport younger specialisation more intense training higher levels of competition a lack of free play increasing medical and public awareness of ACL reconstruction diagnostic improvements The availability of MRI Increase in access to orthopaedic surgeons Mostly a non-contact rotating injury with a pop. A sense that the knee ‘went out’, ‘gave way’ or ‘dislocated’. Immediate swelling. Prevents pathologic anterior excursion and rotational instability. Treatment – Reconstruction. NB not everyone with a disruption needs an ACL reconstruction. The indication for surgery is a symptomatically unstable knee affecting the patient’s function. Sports Injury Prevention in Kids – FIFA 11+ kids = Designed for children <14 yrs Total non-contact injury risk decreased by 52% Improved balance, speed, and agility The Knee Junior Programme = Developed by Netball Australia, released 2015 Junior, senior, and elite levels Complete warm up programme Specifically targets prevention of ACL injuries Evaluation ongoing Footy First = A five-level progressive exercise training program developed specifically to reduce the risk of common leg injuries in community football Groin, hamstring, knee, and ankle. Evidence based, ongoing evaluation Leg Alignment Assessment = 1. 2. 3. 4. 5. 6. Observe and estimate Foot Progression Angle Hip IR and ER (in prone) Thigh-foot angle (tibial torsion) Metatarsus Adductus classification Genu Valgus/Varus Leg length discrepancy Taping = - Always ask about possible skin allergies to tape: Hypoallergenic tape (Fixomull) or spray Provide education +/- warnings re possible skin reactions Apply to clean, dry skin. Avoid lacerations and blisters Shave skin if hairy Rigid tape vs elastic tape (e.g. K-tape, Rocktape) Elastic tape better for younger children with sensitive skin
