Physical Therapy in Pediatric Orthopedics

Physical TherapyTherapy utilizes the treatment methods of physical medicine, including manipulations, exercises, positioning, stimulation, massage, and application of cold and heat. The role of the pediatric therapist is much broader than that of the general therapist, requiring knowledge of growth and development.

The current emphasis on function has improved the effectiveness of therapy programs. Emphasis on effective mobility, independence skills, and communication focuses therapeutic energy and resources on an outcome that optimizes the child’s quality of life.

Physical Therapy

In pediatric orthopedics, the primary focus of physical therapy is on lower limb function and mobility.

Effective mobility A child needs independent and efficient mobility. Without this capability, the child’s psychosocial and educational experiences are significantly limited. The level of mobility should be appropriate to the child’s mental age. The method of mobility is not critical.

Whether mobility is provided by walking or by the use of adaptive equipment, the method of mobility should be manageable by the child himself, conserve the child’s energy, and be functionally practical. Options range from the use of an electric wheelchair to unassisted walking. The objective of management is to provide effective mobility by whatever means necessary while helping the child progress toward a realistic mobility objective. The objective should be an optimistic target within a realistic range. The therapist’s accurate appraisal of the child, knowledge of mobility potential for the disease, and periodic assessments of progress help protect the child from disappointment, frustration, and wasted efforts. With time, objectives may change, depending upon the rate of progress.

A major objective of therapy is support and education of the family. Often, the family has unrealistic expectations that create an additional burden for the child. The family’s major concern often is “Will my child walk?” A better objective would be “Will my child be independent and happy?” Assisting the family and guiding their concepts and expectations is an important role for the therapist.

Infant stimulation programs Helping the parents to interact positively with the child is a vital role of therapy. Parents may be uncomfortable with the infant, and this strained relationship further limits the child. Interactive play therapy, taught to the parents by the therapist, provides the positive physical contact infants need for optimal emotional and intellectual growth. Infant stimulation programs are effective in promoting cognitive, motor, language, and emotional development.

Neurodevelopmental therapy Neurodevelopment therapy (NDT) focuses on motor development. NDT is more effective than the original passive treatment methods but is being replaced by therapy with a broader focus.

Accepting disability Accepting the disability and working around it, using adaptive equipment, is often the most effective management strategy for the child. Usually the physician or therapist cannot cure the disease, but can minimize the disability.

Adaptive equipment is useful to help the child become more independent and functional. Adaptive equipment is useful for the child’s mobility, self-care skills, and communication, and often enhances care of the child by the caregiver.

Exercises are not very useful for the young child because the child lacks the interest and discipline to perform the exercises. Fortunately, children have little need for exercises, as muscle strength and function usually recover spontaneously. Moreover, assistive or stretching exercises can be harmful. In posttraumatic stiffness, stretching often increases stiffness by adding new injury and scarring. Exercise should not be painful. Exercises take on a variety of forms. Chronic passive motion is a new technique for maintaining joint motion following operative release or injury. The joint is moved slowly and continuously through a range of motion during healing.

Stretching is a traditional treatment for contracture. Flaccid contractures respond best to stretching. The prolonged effects of spasticity, as in cerebral palsy, cannot be controlled by intermittent stretching. To prevent contracture, the elongated or stretched position must be maintained for about 4 hours in each 24-hour day. This requires bracing or splinting. Stretching beyond the child’s pain threshold is not advisable; overstretching causes further injury and scar formation.

Therapy at home, with a parent acting as therapist and the therapist as a consultant, is effective and practical when the family is willing and able. Home therapy programs reduce stress on the family by making the treatment more convenient and less expensive. The therapy can often be incorporated into the daily routines, increasing frequency and improving outcomes. Home therapy may also have a bonding effect on the family. This requires parent education and periodic visits to the therapist to assess technique and progress.

Treatments of doubtful value include massage, thermotherapy, injections, and diathermy. These “treatments” are not helpful in pediatric orthopedics.

Occupational Therapy

Occupational therapy focuses on upper extremity function and activities of daily living, including independence skills and correction of deformity. This aspect of therapy plays a broad role in managing childhood disabilities because modern management places greater emphasis on assessment and self-care skills. Physical and occupational therapists often work together, especially for children with long-term disabilities, as part of a management team.

Self-care skills are taught to increase independence in feeding, dressing, and toileting. Self-care can be achieved by learning special techniques from the therapist, using adaptive equipment, or making the environment more easily livable for the child. Independence learned in childhood enhances the individual’s self-respect and happiness and reduces the burden for the family and the costs for society.

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