By Courtney M. Dunn, PT
Current physical therapy practice includes treating a wide array of client populations including adults and children with diagnoses ranging from back pain to postoperative to neurological disorders. The treatment of children by physical therapists is a relatively new branch of the profession. It emerged in the 1940s due to the poliomyelitis epidemic. At that time, therapists provided treatments to children stricken with polio that focused on palliative care, mostly providing braces and stretching exercises. Since these first interventions, the role of the pediatric physical therapist has experienced a paradigm shift with increasing function as the primary focus. Therapists now treat children with a wide variety of disabilities including Down syndrome, cerebral palsy, spina bifida, and orthopedic disorders. With the evolution of this change, therapists working with children suddenly required a vast amount of knowledge related to orthopedic and neurologic diagnoses and treatments. On a daily basis, pediatric therapists integrate the orthopedic knowledge of a sports medicine PT and the neurologic knowledge of a highly trained rehabilitation therapist in order to treat a child using a holistic approach. And as reimbursement becomes a larger issue, therapists are forced to provide these services in shorter lengths of time. Premature Infants Current trends in pediatric therapy are being driven by vast medical advancements in both the diagnosis and treatment of children with disabilities. A great change happening nationwide is the increasing survival rates of premature infants. Infants are now being saved as early as 24 weeks gestation. Many of these infants display developmental disabilities that require therapeutic intervention. As these numbers grow, the ability to identify children with early delays of development has been refined, allowing physical therapist to provide care not only in the neonatal intensive care unit, but also immediately following discharge. As the referral age continues to decrease, therapists are required to treat prophylactically. The therapist must not only treat what the child looks like on a given day, but also treat how the child will present in 3, 5, even 10 years down the line.1 In order to efficiently provide this intervention, therapists must possess an intimate knowledge of normal development as well as a solid grasp of how a diagnosis affects development throughout the patient’s lifetime. Provision Environments Intervention at an early age and the move to address children’s function in their natural setting have fueled a change in provision environments. Therapists are spending more time in the home setting providing care with the family present. The family is viewed as an intimate member of the therapy team, assisting with goal development and treatment approaches. For children under the age of 3, the family and a team of teachers and therapists develop an individualized family service plan (IFSP). The IFSP outlines functional goals to assist the child in gaining the highest level of independence in their home setting. At the age of 3, the IFSP may evolve into an individualized education plan. These plans, implemented under the Individuals with Disabilities Education Act (IDEA), specify the provision of services for children with disabilities within the school. These services may include physical therapy. School versus clinic therapy continues to be a debated topic, although each plays a large role in the life of a child with a disability. School therapy addresses educationally appropriate gross motor goals.2 An example may include providing services to teach a child in a wheelchair how to open doors in the school in order to independently move throughout the facility. At times, school therapists serve more as consultants for children, making sure their environments are fully accessible, rather than providing hands-on care. Clinic therapy is aimed to address the medical model of therapy. This focuses on treating impairments such as muscle length, strength, and tone in order to increase functional level in the home and community settings. Spasticity The new management of spasticity in children has fueled the development of pediatric physical therapy. Medical management in the past has included oral medications such as diazepam and baclofen, nerve block injections of phenol, and muscle lengthening. New procedures and advances in older procedures are dramatically affecting function while offering fewer side effects. These medical approaches often allow surgical intervention to be postponed for several years as well as assist with prevention of typical musculoskeletal deformities such as hip subluxations and contractures. The selective dorsal rhizotomy (SDR) procedure includes selectively cutting afferent, or sensory, roots at the spinal cord level. This decreases the amount of sensory input received in the spinal cord and results in decreased spasticity. This procedure has been modified greatly since its beginning in 1898. It was reintroduced as an accepted intervention in 1981 with significantly fewer root levels being cut, allowing clients to maintain a greater level of function while maintaining the benefits of reduced spasticity.3 Physical therapists play a large role in this intervention pre- and post-surgery. The therapist is often part of an interdisciplinary team that evaluates clients to determine the appropriateness of the procedure. Following the surgery, clients receive aggressive therapy, usually five times per week initially. The focus of therapy includes strengthening of weakness masked by spasticity, introduction of new movement patterns previously impaired by increased tone, and progression of functional activities including transitions and ambulation. The challenge for therapists includes teaching the clients, who can be as young as 2 years old, how to use a body that moves and functions very differently than before the surgery. Another change in spasticity management includes a new method of administering the antispasticity medication baclofen. Baclofen, when delivered orally, requires a high dosage, as the medicine does not easily cross the blood-brain barrier.4 Now Baclofen can be administered directly into the interthecal space via a pump placed in the abdomen. Since the medication is delivered directly to the spinal cord, a much lower dosage is required.4 Spasticity management is achieved without the serious side effects that accompany high doses. The pumps can be placed in children as young as 3 to 4 years old, and they can also be used in older clients who have experienced progressively increased movement limitation through the years of puberty and growth spurts. The role of the therapist following pump placement is similar to that following an SDR. The clients are suddenly provided with a wide range of new movement possibilities, which the therapist refines and progresses to result in an increased function level. Another advancement in spasticity management includes the use of Botox® (botulinum toxin A). This procedure injects specific muscle bellies with a derivative of the botulinum toxin. The results include a weakening of the muscle for 3 to 6 months.5 The muscle groups often injected for gross motor gains include the gastrocnemius, the hip adductors, and the medial hamstrings. This procedure is temporary, but can be performed serially in muscles. Therapeutically, casting often follows injections to place shortened, tight muscles in sustained lengthened position to allow for a stretch to occur. While the Botox is in effect, physical therapists focus on strengthening antagonist muscles as well as encouraging development of strength in spastic muscle in appropriate phases of gait and transitions. The therapist also assumes the role of modifying/altering current braces and orthotics to allow for the newly attained movement to be utilized to the greatest extent. As these nonsurgical interventions have become more standard practice, the pediatric physical therapist is pushed to also assist with delaying or preventing the need for surgical interventions. With each passing year, new approaches to handling and treating children with disabilities transpire. Several techniques have become typical standard of care, with more research emerging to support the theories. Neurodevelopmental technique or NDT was begun in the 1940s by Karel and Berta Bobath.6 This theory is a goal directed approach of increasing functional abilities through facilitation of normal movement patterns. This technique stresses obtaining optimal musculoskeletal alignment followed by active participation of the client in using the new positioning during functional activities such as transitions, activities of daily living, and ambulation. This theory has adopted a motor learning approach that includes repetition of tasks in different environments and at different rates in order to allow the client to fully master a given task. In order to be trained in pediatric NDT, therapists must pass an 8-week course focused on the treatment of children with disabilities. Back to Basics Pediatric physical therapy is also displaying a back to the basics approach: stretching and strengthening. Children with a variety of disabilities, from Duchenne’s muscular dystrophy to cerebral palsy, encounter decreased muscle length and strength. To increase strength, therapists are turning to technology. When a disability is not present, children often strengthen through conventional means, like leg lifts and squats. This is not always feasible when a disability is present. Spasticity may override the ability of the child to perform specific exercises or the weakness is so great that the exercises are impossible. Electrical stimulation is being used as an adjunct to therapy in these cases. Electrical stimulation introduces electrical impulses directly into the muscle fibers. This technique was developed by the Soviets in 1972 and was used to assist their Olympic athletes in preparing for competition. In treating children with disabilities, less aggressive electrical stimulation is used. Neuromuscular electrical stimulation (NMES) provides sufficient stimulation to cause a small muscle contraction.7 This is helpful in developing motor planning during functional activities like gait and transitions. Strengthening of specific muscles can also be performed during functional activities with NMES such as increasing ankle dorsiflexion by stimulating the anterior tibialis during the swing phase of gait via a switch attachment on the stimulation unit. A second method of stimulation, threshold electrical stimulation (TES), uses a lower frequency affecting muscles at a sensory level, generally while the child is sleeping. The theory behind this technique is that the current provided during the night stimulates the growth of muscle fibers, which can then be used to gain strength during functional activities while the child is awake.7 Length of muscles can be gained by two methods: a short manual stretch and a sustained stretch. The effects of a short duration stretch of 20 seconds generally last 24 hours. Sustained stretching, at least 6 hours in length, appears to be more effective in preventing contractures in children with cerebral palsy.8 Night positioning aids such as knee immobilizers, abduction pillows, and ankle casts provide this prolonged stretch in an effective manner. Pediatric orthotics Strengthening and stretching are being combined throughout a child’s day by the use of taping and bracing techniques. Current trends of pediatric orthotics include providing ideal alignment through the foot and lower limb while allowing greatest function and gains of strength. High temperature thermoplastics are being used to fabricate these new orthotics, making the braces lightweight and flexible. The use of contoured footplates supports the arches of the foot and places the bones of the foot in optimal biomechanical alignment. Trim lines of the orthotics have been reduced when possible, including orthotics that rise only above the ankle bones (supramalleolar orthotics) to allow strengthening of the ankle dorsiflexors and plantar flexors. The use of rigid and elastic tapes assists with increasing range and strength by encouraging improved alignment of specific muscles for extended durations of time. This allows overstretched muscles the opportunity to work in a shortened position while shortened muscles are placed in a sustained stretch. Areas often targeted by taping by physical therapists include excessive hip rotation and excessive rotation of the tibia and fibula under the femur. Two theories are used to increase muscle length by addressing the mobility of surrounding tissues. The first, myofascial release (MFR), addresses muscle length at the fascial level. Fascia is a continuous layer of connective tissue present throughout the body lying directly beneath the skin and above muscle. Craniosacral technique addresses limitation of mobility of fluid in the spinal column and in the tissues encompassing the brain. Each theory uses light touch techniques to release adhesions that limit movement patterns or cause pain. As handling and facilitation techniques evolve, so do the mediums in which the services are provided. New environments such as therapy pools and horseback riding are becoming adjuncts to more typical therapy services. Aquatic therapy allows for children who have limited mobility to experience a wide variety of movements with gravity eliminated. Children who have decreased body awareness and display fear of movement also benefit from the pool setting because of the total contact sensory input the pool provides. Therapy with horses, or hippotherapy, is also becoming more widely known. Sometimes referred to as therapeutic horseback riding, this addresses strength, tone, balance, and gait. The benefits of riding include decreasing tone due to the horse’s warm body temperature, the steady gait pattern that simulates the timing of human gait nearly perfectly, and the challenges to balance and strengthen while also having fun. Pediatric physical therapy has evolved greatly over the past 60 years. A greater focus on achieving the highest level of function for children with disabilities prevails with a team approach to the intervention. The training of the pediatric therapist includes an intimate knowledge of development, kinesiology, and musculoskeletal alignment. In applying this knowledge, therapists combine numerous techniques and modalities to achieve an optimal outcome for children and their families. N Courtney M. Dunn, PT, is a staff physical therapist at Cleveland Clinic Children’s Hospital for Rehabilitation. References
Bly L. Baby treatment based on NDT Principles. Therapy Skill Builders. 1999:1-10.
Tecklin JS. Pediatr Phys Ther. 2nd ed. Philadelphia: JB Lippincott Company; 1994:446-455.
Steinbok P, Reiner AM, Beauchamp R, Armstrong RW, Cochrane DD, Kestle J. A randomized clinical trial to compare selective posterior rhizotomy plus physiotherpay with physiotherapy alone in children with spastic diplegic cerebral palsy. Dev Med Child Neurol. 1997;39:178-84.
Albright AL, Barron, WB, Fasick MP, Polinko P, Janosky J. Continuous intrathecal baclofen infusion for spasticity of cerebral origin. JAMA. 1993;270:2475-2477.
Gooch JL, Sandell TV. Botulinum toxin for spasticity and athetosis in children with cerebral palsy. Arch Phys Med Rehabil. 1996;77:508-11.
Bly L. A historical and current view of the basis of NDT. Pediatric Phys Ther. 1991;3:131-135.
Pape KE. Therapeutic electrical stimulation (TES) for the treatment of disuse muscle atrophy in cerebral palsy. Pediatric Phys Ther. 1997;9:110-112.
Tardieu C, Lespargot A, Tabary C, Bret MD. For how long must the soleus muscle be stretched each day to prevent contracture? Dev Med Child Neurol. 1988;30:3-10.
