Pediatric Physical Therapy Essay: Assessment And Treatment Strategies For Posture.

Assistive technology and seating systems

Describe about the Pediatric Physical Therapy for posture in a sitting system?

Assessment of a posture in a sitting system become critical since most of the patients with deformities are completely unable to walk or may be able to walk for a short distance. Therefore, it is important to start with, the assessment of posture of disable children in a seating system. Assistive technology (AT), as well as AT services for the children who are suffering from disabilities, are now considered as the part of the "pediatric physical therapy practice." It is observed that the increasing availability of technology as well as federal legislation, which supports the use of Assistive Technology (Sweeney et al., 2010). The seating system and its apparatus should be prepared in such a way that support the child in his or her specific activity as well as it allows the child to roam independently. To develop the seating system, it is important to start with the seating assessment (Brien & Sveistrup, 2011). During seating assessment, the clinicians need to examine both the seating position and supine of the children. Assistance may be needed to stabilize the body parts while assessing the seating posture. The clinician must examine the lumber movement while the child is in the supine position (Frank et al., 2011). If the examiner found, the pelvic movement is present then it becomes easy to determine the impact of leg positioning on the pelvis. The clinician needs to make the patient is sitting on a surface, which has the thin top in order to measure the knees to flex. This is helpful in the assessment of posture in a seating system.

Anti-thrust seat

The anti-thrust seat has several features, which are specially designed to support the children with disabilities as well as the adults with neuromuscular or neurological impairment. The anti-thrust seat is prescribed to the patients who are suffering from a severe disorder in their sitting position (Downey & Rapport, 2012). This is helpful for the patient as its dense foam helps to rise the front of the seat to support the pelvis set back in the seat. On the other hand, the top layer of "Visco foam” is helpful to add comfort and optimal support. The Anti-Thrust Seat is fully customizable to provide full comfort to the patient. It is found that an Anti-Thrust Seat cups the pelvis with an anterior, which is block formed (Ragonesi et al., 2010). If the seat is too deep, then the undersurface of the thigh need to be provided extra support.

Seating assessment for posture in a sitting system

Anteriorly tipping the seat

From previous researches, it is found that people who are suffering from spinal cord injury, as well as neural tube defect, pointed out that anteriorly tipping the seat of 20⁰ is helpful to reduce the pressure under the pelvis. From different research papers, it is found that there is a lack of evidence to guide and support the use of anteriorly tipping the seat for the people with neuromuscular impairment as well as neurological problems (Ganley et al., 2011). No studies identified the impact of the seat tilt on people with muscular dystrophy. However, it is discovered that patients who are suffering from cerebral palsy become benefited from the use of anteriorly tipping of seat.

Lateral trunk support

Lateral trunk support is considered as the dynamic and innovative body support, which is designed to provide flexibility and unparallel comfort. Most of the patients who are suffering from neurological disabilities such as cerebral palsy are mostly recommended for the use of Lateral trunk support (Fowler et al., 2010). There are three points for trunk stabilization such as the lateral trunk, the anterior trunk, and the posterior trunk. Good posture refers to the result of the balancing of the skeleton with the gravity. The lateral trunk support help to maintain an ideal posture of the patient, which includes neutral alignment, level shoulders, the shoulder is slightly posterior (at 100⁰) to the pelvis and maintain a neutral pelvis (Umphred et al., 2013). The long-term effect of using lateral trunk support is to increase minimize the orthopedic consequences, increase the mobility of the user, normalize muscle tone, provide pressure relief and reduce the requirements for the active muscle.

Abductor pommel

According to the general guidelines of the physicians, symmetrical hip abduction is considered as one of the well versed and important conditions for “proper posture.” From studies, it is found that abduction pommel is useful to allow equal weight bearing through both thighs, ischial tuberosities, which in turn permit better distribution of pressure (Bo et al., 2014). The abductor device is prescribed to the patients who are suffering from postural deformities. Not only adults but also the children are recommended to use abductor pommel. The abductor pommel is considered as the effective device, which can be used in different situations and therefore, recommended by most of the physicians.

Scheuemann’s disease

Scheuemann’s disease is known as the self-limiting skeletal disorder, which happens in childhood. This disease was named after Holger Werfel Scheuemann’s. Scheuemann’s disease signifies the physical condition where the vertebrae show growth in an uneven manner respect to the sagittal plane (Bhat et al., 2011). In this case, the posterior angel is often become larger than the anterior. It is found that the uneven growth of the vertebrae can result in the "wedging" shape, which is the signature of kyphosis disease.

Anti-thrust seat for seating support

Etiology

Scheuermann’s disease is considered as a condition, which develops increased thoracic kyphosis (>40°). This disease shows true postural changes of 5⁰ wedging within the thoracic vertebra (in all of three vertebrae, which are adjacent). The apices are commonly found between T₇ and T₉. However, it is also found that the localized deformity in this caused by this disease is painless (Wiart et al., 2010). It is also discovered that there are strong hereditary pattern remains of the Scheuermann’s disease. The changes caused in the disc and vertebra is recognized to reflect the “physical stress.” Clinically most of the children are affected by the Scheuermann’s disease. In most of the cases, children between 10-15 are diagnosed with Scheuermann’s disease. There are several characteristics found in the patient with Scheuermann’s disease, such as irregular lower and upper vertebral endplates, the loss of disc space height, wedging of vertebrae more than 10⁰. In addition, it is also found that the presence of hyperkyphosis is more than 40⁰.

Clinical presentation

There are different clinical symptoms showed by the Scheuermann’s disease. Such as-

Patient with Scheuermann’s disease presents kyphotic deformity, which is demonstrated best in the “forward flexed position.”

Decrease flexibility of the spine, which showed the structural nature of kyphotic deformity.

The patient may feel palpation or tenderness below and above the apex of kyphosis.

Lower thoracic kyphosis is observed at the thoracolumbar junction.

The patient may show the presence of Hamstring tightness.

The patient may show hyperlordosis in the lumbar spine.

However, it is also found that neurologic deficits are very rare in the case of Scheuermann’s disease.

Intervention

The treatment of Scheuermann’s disease is found to very controversial. Some of the researchers think that the thorasic Scheuermann’s disease is benign, which emphasize that most of the clinicians show their reluctant towards the treatment of the Scheuermann’s disease. On the other hand, in some cases clinicians recommended some exercises; however, those are very painful. Patients who are suffering from the mild and non-progressive disease could be treated with reducing weight and relieve from weight bearing stress (Palisano et al., 2012). Patients with Scheuermann’s disease are always recommended not to perform any strenuous activity. Although in some cases exercise proved as beneficial, it is also found that exercise alone cannot help to relieve the patient from the pain of disease.  In addition, using of the brace was also proved as significant in order to relieve the patient from suffering. Most of the clinicians recommended for duPont kyphosis brace and modified Milwaukee brace.

Anteriorly tipping seat to reduce pelvis pressure

Apart from these interventions, there are also several surgical interventions to treat the disease. However, most of the patients do not readily accept surgery as it is painful and produce unacceptable cosmetic appearance. Cord Decompression is introduced for the patients who have neurologic deficits or increased kyphotic angulation though it is very rare. If the instrumentation is failed, then pseudoarthrosis can occur (Gordon et al., 2011). People who were treated with surgery or bracing in both cases experienced relief; however, the disease is not cured. The other factors that can help in the treatment are conservative treatment, which may include the use of body cast plus brace as well as exercise regimen and the presence of the Risser sign of skeletal maturity.

Femoral anteversion is known as inward twisting of the femur (thighbone, which is located between knee and hip). This disease causes the feet, the knees of the child turn inward, and the appearance looked like “pigeon-toed” (Oetgen & Peden, 2012).  

According to the case study, the foot progression angle is -35⁰, which emphasize that the patient with femoral anteversion have a complete distortion of feet, however, it is not very much effective for the children with normal bone alignment. In this case, the physician can recommend proper exercise for the patient.

According to the case study, the internal rotation of the hip is 75⁰, which is not normal. The internal rotation of the hip is 75⁰ emphasize the abnormal limb structure of the child with femoral anteversion. To help the child specific exercises can be recommended.

According to the case study, external rotation of the hip is 20⁰, which can cause pigeon shaped posture for the child who is suffering from femoral anteversion. In this condition, the physician can suggest using brace. However, a child with normal bone alignment does not need any medical intervention.

According to the case study, the thigh-foot angle is -5⁰, which can also form pigeon like posture for the child who is suffering from femoral anteversion. In this condition, the physician can suggest using brace. However, a child with normal bone alignment does not need any medical intervention.

From studies, it is observed that most of the children tend to toe-walk for some time when they first started walking independently. This is quiet natural and does not consider as the symptoms of cerebral palsy. This is idiopathic toe-walking (ITW) and can be treated by therapeutic exercises (Williams et al., 2010). Primarily toe walking consider as a gait abnormality, which is characterized by an absence of normal heel strike (heel to floor contact) by both feet. Toe walking shows several etiologies, which include severe neuromuscular disease to idiosyncratic disease. The treatment of toe walking depends on the severity of the abnormality and the age of the children (patients).

Lateral trunk support for trunk stability

There are two types of medical interventions can be taken to treat toe walking, such as medical therapy and surgical therapy. The non-operative or conventional medical treatment of toe walking includes orthotics, casting, stretching and chemodenervation. In chemodenervation treatment botulinum toxin (BOTOX) could be used (Zwicker et al., 2012). However, the success of these treatment depends on the age of the patient. Stretching is the first treatment used by the physician as this process is least invasive; however the success of treating idiopathic toe walking is very limited. On the other hand, serial casting is used to stretch the Achilles tendon. These casts can easily change weekly, depending on the progress level. A custom orthotic such as AFO (ankle-foot orthosis) could be used to treat ITW, especially for children. However, if the conventional methods of treatment failed, then surgical therapy can be used to treat ITW. Through the medical incision, an open heel-cord lengthening could be done. Another method is open and percutaneous technique, which is also very popular.

The spastic diplegia is also known as Little’s disease. The spastic diplegia is a form of cerebral palsy just like idiopathic toe walking. The spastic diplegia is considered as a chronic neuromuscular condition of spasticity as well as hypertonia. Although these two diseases has many similarities, it is found that there are also several differences (Gordon et al., 2011). The gait pattern observed in children with idiopathic toe walking is not similar with those who are suffering from spastic diplegia. In spastic diplegia, it is observed that the lower parts (muscles and motors of the lower limbs) are stiffened. On the other hand, toe walking could be caused due to the habit of the children and do not stiffen the lower limbs as much as spastic diplegia do.

Reference

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