Paediatric
Physiotherapy
HOW WE CAN HELP
Content
Who are Paediatric Physio’s?
What do they do?
How can they help?
Paediatric Physiotherapy at Perform
CP Fitness
Developmental Gait Abnormalities
When to refer
Paediatric Specific Musculoskeletal Disorders
Children are not mini adults
What Do We Do?
The Paediatric Physio
Hospital Based Specialists – Acute Care
Community Team
Independent Therapists
Hospital Based Specialists
Respiratory
PICU / CF / Asthma / Acute Respiratory / PCD / Breathing disorders / Home
Ventilation / Outpatient clinics
Neuro
Head Injuries / Stroke / Transverse Myelitis / Encephalopathy / Oncology / Guillan
Barre Syndrome /Regional Neuromuscular Clinics/ Botox Clinic/ Complex Tone
Clinic
Neonates
NICU / Torticollis / Erbs Palsy/ Arthrogryposis / Neuro Developmental Therapy /
Follow up Clinics
Orthopaedics
Surgical Rehab / Scoliosis / Ilizarov Frames
Rheumatology
JCA / JDM / Hypermobility Syndrome
Community Paediatric
Physiotherapists
Chronic Disability - Cerebral Palsy/ Neuro Muscular Conditions /
Chromosome Abnormalities / Head Injuries
Gross Motor Delay
Home Visits
School Liaison – Programmes / EHCP reports / MDT meetings
Therapeutic Equipment / Orthotic provision
Independent Paediatric
Physiotherapists
Independent Paediatric Therapy Centres – MDT
Neuro Rehabilitation Centres – CP/ SDR Rehab / ABI
Case management / Personal Health Budget / Paediatric
Musculoskeletal / Developmental Co-ordination Difficulties /
Hemiplegia / Learning Difficulties / ASD
Perform – Unique Rehabilitation Environment
Perform
The Perform Centre is a state of the art sports science and
rehabilitation facility.
Unique setting for paediatric neuro rehab
Sports / Fitness / Medical MDT
Motivating
Training sessions
Teenage friendly
Common Referrals
Hypermobility Syndrome
Co-ordination Difficulties
Cardio Vascular Conditioning
Sports Injuries
Neuro Rehab
Developmental Gait Abnormalities
Postural Advice
CP FITNESS
What is CP Fitness?
CP Fitness is a gym based group exercise class for
children aged 7-17 years who would benefit from
physiotherapy led exercise/rehabilitation within a group
setting.
This class is not exclusive to children with cerebral palsy
(CP) however it is focussed on neuro/developmental
rehabilitation rather than musculoskeletal / sports injuries.
CP Fitness aims to provide:
Accessibility to fitness for children with physical
disabilities / reduced mobility
Supported rehabilitation following
Orthopaedic surgery
Clinical Intervention
Illness
Why CP Fitness?
Exercise Guidelines for 7- 17 olds
60 minutes per day required to stay healthy Department of Health 2010
Activity should include aerobic exercise; playground
games, cycling, running, dancing and strengthening
exercises; gymnastics, jumping, ball sports, martial arts.
For a child with a physical
disability?
Reduced Activity Levels
Poor Cardio Vascular Conditioning
Compromised Physical Functioning
Secondary Health Issues as a Result of
Reduced Activity
Weight gain
Joint contracture
Muscle weakness
Respiratory Infection
Fatigue
Loss of motor skills
Loss of Self-esteem / Reduced Confidence / Depression
CP Fitness aims to provide a safe,
motivating, meaningful environment
where children who are experiencing
reduced activity levels due to
physical limitations can come to
improve their fitness and strength with
the ultimate outcome of improving
their future health and function .
Who We Can Help
Cerebral Palsy (GMFC , I, II and III)
High functioning neuro rehab
Developmental Co-ordination Difficulties
Hypermobility Syndrome
Respiratory Disease
Obesity
Oncology Rehab
Other Services
1:1 Physiotherapy Sessions
Assessment and Advice
Under 3’s Outpatient Service
Developmental Assessment
Developmental Gait Abnormalities
Flat feet
Intoeing
Out toeing
Varus knees
Valgus knees
Toe walkers
[Link]/publications
Flat Feet
Normal up to 3yrs of age
Usually corrects by 6-7yrs
Jack’s test (Windlass effect)
When to refer a flat foot
If pain, functional problems or pressure areas refer to physio
Physio will assess and identify cause of problem i.e.
Hypermobility
Tightness
Flexible vs rigid foot
Rigid due to tarsal coalition
Exercises
Stretches
Orthotics
Intoeing
Femoral Anteversion
Normal between 3-8 years
Twice as common in girls than boys
Neck of femur more anteriorly angled
Patients intoe to better position femoral head
Craig’s Test
At birth femoral anteversion is
between 30-40 degrees
Adult Femoral anteversion is
approximately 15 degrees
Internal Tibial Torsion
• Normal variant between 1-3 years
• Measure by placing child in prone
therefore eliminating hip rotation and
flexing knee to measure foot progression
angle.
• Normal range is 0-20 degrees
Metatarsus Adductus
Adduction of the forefoot on the
rear foot
Best seen viewing sole of foot
Line through heel should pass
between 2nd and 3rd toes
If severe adduction line passes
through 4th and 5th
Resolved by 7 years
When to refer an intoeing child
If no symptoms and no functional difficulties reassure child and
parents that correction can occur up to 8 years of age
Advice
If pain or functional difficulty refer to paediatric physiotherapist
We will assess
Biomechanics
Strength
Flexibility
Function throughout lower limb and trunk.
Out toeing
Usually morphological
Femoral retroversion
SUFE
Varus knees
Normal up to 18 months
Babies born with varus alignment
Asymmetrical, progressive or painful refer to orthopaedics
Possible causes Rickets, metabolic disorders, skeletal dysplasia,
blouts disease
Valgus knees
Normal up to 7/8 years
Usually developmental femoral ante version which remodels with
stresses on femoral neck
No referral unless pain or functional limitation
Physiotherapy will assess
Strength
Joint range/muscle length
Biomechanics
Toe Walking
Bilateral
Can be a variant of normal in early gait
As gait matures 18-20 months should reduce
Unilateral
Consider neurological involvement
Leg length discrepancy
Toe walking after 2 years exclude diagnosis of
DMD, check gowers and hypertrophy of gastrocnemius
Often associated with sensory disorders such as ASD
Cerebral Palsy
Treatment
If no clinical concerns and child able to
Walk with heelstrike when requested
Has full passive range of dorsiflexion
Advice to
Wear stiff ankle boots
Discourage excessive planterflexion in stance
If toe walking persists or becomes problematic refer on to
paediatric physiotherapy
Physiotherapy Treatment Options
for Toe Walking
Stretching
Strengthening
Taping
Splinting/casting
Gait re education
Paediatric Specific
Musculoskeletal
Pathology
Children are not mini adults
Pathology different in adults and children particularly
during growth spurts that herald the onset of
adolescence
Symptoms of musculoskeletal pain in the developing
child are usually directly related to area of growth within
the developing skeleton, the injuries and affectations of
which largely make up the field of paediatric
orthopaedics.
If problems not picked up injury can lead serious
consequences
Musculoskeletal Pain in Children
Conditions affecting the articular surface of joints,
the growth plate or around sites of secondary
ossification within epiphyses
Non-infective derangements of bony growth seen at
times of greatest skeletal development
Osteochondroses
Categorized according to location
Classification of Osteochondroses
Articular epiphyseal lesions/osteochondritis dissecans
(pressure epiphyses)
Perthes/Scheuermann’s
Physeal lesions – growth plate lesion
SUFE/Salter Harris Fractures
Apophyseal lesions/non articular (traction epiphyses)
Osgood-Slatters/Severs
Articular Epiphyseal Lesions
Disruption to vascular supply to epiphysis or trauma
Necrosis of sub chondral bone/malformation/weakness
Seen most commonly in hip, knee, ankle, foot elbow
Swelling, altered weight bearing, pain on joint line
Treatment is NWB/PWB surgery if not settled in 1 year
Physeal Lesions
Growth plate lesions
? Due to trauma, repeated micro trauma, alteration of blood flow
High risk during a growth spurt
Twice as likely in boys peak at 12 years, girls 11 years
Common sites are hip, radius, ulna, humerus, tibia, fibular and fingers
Watch for tenderness over growth plate in sporty, or overweight
children
Worth a physio referral to check biomechanics, flexibility,
conditioning/fitness
Apophyseal Lesions
A Traction epiphysis/apophysis is an area of skeletal tissue
under a tendon insertion
Injuries to this area are either
Apophysitis
Avulsion
These injuries occur due to the
extreme vulnerability of the
epiphysis in these areas.
To Summarise
Beware of musculoskeletal pain in adolescents
Pathology likely to be related to growth and associated
skeletal vulnerability
If not settling refer to a paediatric physio for advice or
directly to orthopaedics if you feel x-rays are required
How to Refer to Paediatric
Physiotherapy
Contact Perform
Tel: 02380 764348
Fax: 02380764377
Email: sophysio@[Link]
Any Questions?
