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Orthopedic ManualTherapy for thePediatric PatientMitchell Selhorst, DPT, OCSNationwide Children’s Hospital Sports and Orthopedic PTColumbus, Ohio . .

Learning ObjectivesThe attendee will: Understand the specific precautions and therelative risk of performing orthopedic manualtherapy on pediatric patients. Identify pediatric patients who are appropriatefor orthopedic manual therapy. Use orthopedic manual physical therapy tominimize pain and maximize function in pediatricorthopedic patients. . .

Pediatric Physical Therapy . .

This is the Pediatric I Mean

Kids Need PT Too!

Pediatric Pain is Not Benign Injury in childhood may lead to increasedrisk of pain in adulthood.23 Pain does not go away on its own– 2/3 of adolescents with low back pain willhave chronic or recurrent symptoms 6 monthslater.38

Clinical Practice Guidelines Recommenduse of Manual Therapy

Alright, Let’s Do Manual Therapy!Wait Growing Children . .

Contraindications and Precautions Contraindication: A circumstance whichabsolutely rules out the use of atherapeutic method which would otherwisebe indicated. Precaution: The risks of a treatment haveto be carefully assessed before treatmentis initiated, and it can only be administeredif its benefits to the patient are greaterthan its risks . .

Why are Children a Precautionfor Manual Therapy?Controversial: Not all authors agree that agrowing child is a precaution. Growth plates and cartilage endplates Ability to give informed consent Lack of research . .

Growth andCartilage End PlatesGrowth PlatesAge of OssificationWrist17‐19 yearsElbow15‐18 yearsShoulder19‐25 yearsHip18‐25 yearsKnee19‐25yearsFoot and Ankle18‐20 yearsEnd PlatesAge of OssificationCervical16‐18 yearsThoracic16‐18 yearsLumbar16‐18 yearsSacrum18‐25 yearsFemales 1-2 years sooner than males

Forces of Manual Therapyvs Normal Activity

What is the Risk MT willdamage a growth plate? Unknown: No documented case of growthplate injury has occurred due to manualtherapy.– 10,000,000 manual therapy interventionsperformed on children every year.– 2.3 million performed in the US alone.31 . .

Gaining Informed Consentfrom a Child A minor cannot provide informed consent Discussion of the risks and benefits ofmanual therapy becomes a familydiscussion

Risks from Lack of Research Children are not tiny adults, manyresearch results are not generalizable. We don’t know what we don’t know . .

Children are Not Tiny AdultsI wish I had hairSkeletally MatureAvoids Activity90% NonSpecific LBP?I have hairGrowth PlatesRemains Active 50% NonSpecific LBP?

Ruling out Cancer for Back Pain Negative on all 4 of these 100% sensitive– Age 50 years of age– Previous history of cancer– Unexplained weight loss– Failure to improve with conservativemanagement . .

Rely on your Red Flags Persistent painIncreases at restProgressive neurological deficitsAssociated feverNight painBowel or bladder incontinence . .

Ruling out Fractures Ottawa Ankle Rules28OK! Ottawa Knee Rules37OK! Canadian C-Spine Rules STOP!-Patients 10 years12OK!-Patient 10 years12 Not Sensitive Enough

Can we use CPR’s to guidemanual treatment? Manipulation for low back pain14– Pain for 16 days– No pain distal to the knee– 1 Lumbar segment hypomobile– Hip IR 35 degrees– FABQ-work subscale score 19?10-30% more hip IRmotion in children

Can we use a Modified CPRfor Lumbar ManipulationPatient meets 3 out of the 4––––Pain for 16 daysNo pain distal to the knee1 Lumbar segment hypomobileHip IR 35 degreesORPatient have both of the following-Pain for 16 days-No pain distal to the kneeIn a RCT assessing lumbarmanipulation in adolescents,only 5% met either of thesemodified rules. Unable toassess the effectiveness ofthese CPR’s.38

How to Identify AppropriatePatients for Manual TherapyDoes the clinician think the patientwould benefit from MT?NoYesYesContraindications?NoYesDo risks outweighthe benefits?NoNo improvementManual TherapyNot AppropriateTrial MTPositive Outcome.Continue as Indicated

Case of Low Back Pain13-year-old female– 2-month hx of LBP– Insidious onset– Has not improved overpast 4 weeks– No report of pain, NT, orweakness in LE’s– No red flags noted duringevaluation

Case of Low Back Pain13-year-old female with 2-month hx of LBP-Recreational dancer (Hip Hop and Ballet) 4hours of class a week.-Pain is worse with activity(2/10 at rest 6/10pain during dance)-Pain increases by 2/10 with lumbar extension-Scored a 14/30 on Patient Specific Functional ScaleDance 4/10Bending backwards 5/10Walking for 20 minutes 5/10

Should We Utilize ManualTherapy with this Patient?

Treatment Consideration forthe pediatric lumbar spine Much of pediatric back pain has ananatomical cause, some can beprecautions or contraindications to manualtherapy Up to 50% of adolescent athletes with lowback pain have a spondylolysis orspondylolisthesis.43

SpondylolysisTypeNamePathogenisisType IDysplasticCongenital abnormalitiesType IIIsthmicStress fracture in the parsinterarticularisType IIIDegenerativeDegeneration of the intervertebraldiscsType IVTraumaticAcute fracture in areas other thanparsType VPathologicalBone disease, tumor, or infection

Grades of SpondylolisthesisGrade of ‐listhesisGrade I% Slippage of thevertebral body1‐25%Grade II26‐50%Grade III51‐75%Grade IV76‐100%

Pediatric Spondylolytic InjuryAcute LesionChronic LesionLesion with anterolisthesisIncreased uptake (SPECT)or edema (MRI) noted inthe symptomatic regionLesion diagnosed but nosigns of active healingnoted on imagingGrade I‐IVCan be determined byX‐ray, CT, MRIActive fractureManual Therapy iscontraindicated in regionFibrous lesion, unlikely toachieve bony union.Manual Therapy is aprecautionPrecaution orContraindicationDepending on Grade andstability of ‐listhesis

Are there contraindication formanual therapy?13-year-old female with 2-month hx of LBP– ImagingX-ray - NegativeMRI - Negative

Risk and Benefits of ManualTherapy with this Patient? Physical therapy, including manualtreatment, results in significantly betteroutcomes in children with back pain.1 Lumbar manipulation does not increaserisk of an adverse event in adolescentswith non-specific low back pain.38

Trial Manual Therapy!

A Case of Neck Pain9-year-old male injured hisneck 3 days ago whiletackling in youth football.– Current patient (left shoulder)– Reports 7/10 right midcervical pain– No report of numbness ortingling– Significant TTP of R C3-4

A Case of Neck Pain9-year-old male injured duringyouth football– Patient maintained consciousness– Not a helmet-to-helmet collision– Active cervical ROMFlexion 65 deg. Ext 20 deg.*Rotation L 75 deg. R 50 deg*.– Difficulty sleeping at night due to pain– No signs or symptoms of concussion

Should We Utilize ManualTherapy with this Patient?

Are there contraindicationsfor manual therapy? Unable to rule out cervical fracture.– No imaging to rule out fracture.– Canadian C-spine Rules not sensitive enough. . .

Thumbs Down

A Case of Swimmers Shoulder11-year-old female with R shoulder pain Clinical diagnosis of secondary GHimpingement and multi-directional instability. Generalized hypermobility noted Beighton score of 6 out of 9

A Case of Swimmers Shoulder11-year-old female with R shoulder pain Hawkins-Kennedy Painful Arc ER weakness Excessive anteriorGH joint laxity Sulcus sign- Apprehension

Should We Utilize ManualTherapy with this Patient?

Are there contraindicationsfor manual therapy?Generalized Hypermobility is considered aprecaution by most, a few consider it acontraindication.– When treating a patient with hypermobility, thetherapist should examine opposite motionsand neighboring segments to find out if anyrestrictions exist.

Risks vs Benefits Risks: Manual therapy done incorrectlycould increase the patient’s hypermobilityand multi-directional instability. Benefits: Restoring motion to neighboringsegments could improve proper GH jointmechanics- 2 case studies support thistheory.7, 27

Trial Manual TherapyTarget restricted areas:– Posterior Shoulder– Pec Minor– Thoracic Extension– Scapular thoracic

A Case Acute Ankle Sprain15-year-old male with L inversion ankle sprain– 5-days post injury– Does not participate in sports– Fell off obstacle course androlled his ankle– No imaging performed– Presents to clinic on crutchesand ACE wrap

A Case of Acute Ankle Sprain15-year-old male with L inversion ankle sprain– Patient is able to walk in clinicwithout use of crutches withantalgic gait– TTP at ATFL– Talar Tilt, Anterior drawer (pain)– No tenderness at medial/lateralmalleoli, navicular or base 5thmetatarsal– Mild swelling noted upon visualexamination

Should We Utilize ManualTherapy with this Patient?

Are there contraindicationsfor manual therapy? Rule out fracture with the Ottawa AnkleRules. No other precautions or contraindicationsnoted

Risks vs BenefitsRisks: Minimal. No adverse reaction notedin research for this populationBenefits: Short and long-term benefitsnoted with use of manual therapy for acuteankle sprain.44, 45

Trial Manual Therapy!

Conclusion Manual therapy can be an effective way tominimize pain and maximize function inpediatric orthopedic patients. Weigh the risks and benefits beforeproceeding Rely on patient history, your clinicalexpertise, and the patient’s preferenceuntil there is better research to guide EBP. . .

References1.Ahlqwist A, Hagman M, Kjellby-Wendt G, Beckung E. Physical therapy treatment of back complaints onchildren and adolescents. Spine. 2008;33(20):E721-7. Epub 2008/09/17.2.Alqarni AM, Schneiders AG, Cook CE, Hendrick PA. Clinical tests to diagnose lumbar spondylolysis andspondylolisthesis: A systematic review. Physical therapy in sport : official journal of the Association ofChartered Physiotherapists in Sports Medicine. 2015. Epub 2015/03/24.3.Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy inthe treatment of musculoskeletal pain: a comprehensive model. Manual therapy. 2009;14(5):531-8. Epub2008/11/26.4.Blanch P. Conservative management of shoulder pain in swimming. Physical Therapy in Sport.2004;5(3):109-24.5.Bruggeman G. Biomechanics in gymnastics. Med Sport Science. 1987;25:142 Y 76.6.Calvo-Munoz I, Gomez-Conesa A, Sanchez-Meca J. Physical therapy treatments for low back pain inchildren and adolescents: a meta-analysis. BMC musculoskeletal disorders. 2013;14:55. Epub 2013/02/05.7.Carson PA. The rehabilitation of a competitive swimmer with an asymmetrical breaststroke movementpattern. Manual therapy. 1999;4(2):100-6. Epub 1999/10/06.8.Chen KC, Chiu EH. Adolescent idiopathic scoliosis treated by spinal manipulation: a case study.Journal of alternative and complementary medicine (New York, NY). 2008;14(6):749-51. Epub 2008/08/05.