PTPM008 PTM of Oncology and Palliative Care-related Medic…

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:008 Revision: 01 Page: 1 of 47
PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE
CARE-RELATED PATIENTS
NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons
Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose,
without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons
Health & Wellness at any time.

PHYSICAL THERAPY MANAGEMENT OF
ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS

SPEC. BY: Abdulrehman S. Mulla

DATE: 04/09/2009

REVISION HISTORY

REV. DESCRIPTION CN No. BY DATE
01 Initial Release PT0008 ASM 04/09/2009

Medicine: it’s a noble profession, it serves humanity
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TABLE OF CONTENTS PAGE
ONCOLOGY: 4
1.0 MEDICAL ONCOLOGY: 6
2.0 SURGICAL ONCOLOGY: 7
3.0 RADIATION ONCOLOGY: 8
3.1 BASIC PRINCIPLES OF RADIOTHERAPY: 9
3.1.1 SIDE EFFECTS: 9
3.1.2 WHILE AT THE HOSPITAL EXCEPT THE FOLLOWING: 11
3.1.3 DURING IMPLANT SURGERY: 12
3.1.4 DURING EXTERNAL BEAM THERAPY: 12
4.0 PEDIATRIC ONCOLOGY: 13
4.1 BONES, JOINTS AND MUSCLES: 20
4.1.1 TRAUMA INJURIES: 20
4.1.2 GAIT PROBLEMS: 20
4.2 DEVELOPMENTAL DISORDERS: 21
4.2.1 DEVELOPMENTAL DYSPLASIA: 21
4.2.2 OTHER RISK FACTORS MAY INCLUDE THE FOLLOWING: 23
A. SPECIFIC TREATMENT FOR DDH WILL BE DETERMINED BY YOUR BABY'S PHYSICIAN BASED ON:................. 24
I. PLACEMENT OF A PAVLIK HARNESS: 24
II. TRACTION AND CASTING: 24
III. SURGERY AND CASTING: 24
IV. SHORT LEG HIP SPICA CAST: 24
VI. WHEN TO CALL YOUR BABY'S PHYSICIAN: 25
4.3 BRAIN & NERVOUS SYSTEM: 26
4.3.1 CEREBRAL PALSY (CP): 26
4.3.2 HEAD INJURIES: 28
A. CAUSES OF MICROCEPHALY MAY INCLUDE: ............................................................................................................ 28
4.4 SYSTEM & LUNG: 30
4.4.1 CHRONIC FATIGUE SYNDROME: 30
A. SUGGESTED EXERCISES FOR CFS:............................................................................................................................ 31
4.5 JUVENILE CHRONIC ARTHRITIS: 33
4.5.1 PHYSICAL THERAPY: 34
A. SPLINTING:...................................................................................................................................................................... 34
B. JRA LONG-TERM CONCERNS:...................................................................................................................................... 34
I. COPING WITH JRA: 35
4.6 LUPUS: 36
4.6.1 PHYSIOTHERAPY FOR LUPUS: 37
4.7 RESPIRATION: 38
4.7.1 ASTHMA: 38
A. COMMON SYMPTOMS OF ASTHMA INCLUDE: ........................................................................................................... 38
B. PHYSIOTHERAPY ASSESSMENT: ................................................................................................................................ 38
I. YOUR CHILD’S MEDICATION: 38
C. TREATMENT TECHNIQUES FOR AN ASTHMA ATTACK: ............................................................................................ 39
I. TURNING: 39
II. COUGHING: 39
III. DEEP BREATHING: 39
IV. POSTURAL DRAINAGE: 39
V. PERCUSSION: 39
VI. VIBRATION: 39
VII. PREPARATION: 40
VIII. AFTERCARE: 40
IX. RISKS: 40
X. NORMAL RESULTS: 40
4.7.2 CYSTIC FIBROSIS: 41
A. POSTURAL DRAINAGE AND CPT:................................................................................................................................. 42
I. PURPOSE: 42
II. CHEST PHYSICAL THERAPY POSITIONS FOR INFANTS AND CHILDREN: 43

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1. UPPER LOBES: ............................................................................................................................................... 43
2. LOWER LOBES: .............................................................................................................................................. 43
III. PRECAUTIONS: 44
IV. DESCRIPTION: 44
V. TURNING: 44
VI. COUGHING: 44
VII. DEEP BREATHING: 44
VIII. POSTURAL DRAINAGE: 44
IX. PERCUSSION: 45
X. VIBRATION: 45
XI. PREPARATION: 45
XII. AFTERCARE: 45
XIII. RISKS: 45
XIV.NORMAL RESULTS: 45
4.8 PEDIATRIC PHYSIOTHERAPY: 47

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ONCOLOGY & PALLIATIVE CARE:
ONCOLOGY:
Oncology, at its most basic level, involves the diagnosis and treatment of cancer. The word oncology comes from
the Greek word meaning quot;massquot; or quot;bulk,quot; referring to tumors. A doctor who specializes in oncology is called an
oncologist.
Oncology involves a huge range of study. Since cancer can occur in so many of the body's systems, many doctors
choose to specialize in a particular branch of it, such as bone cancer or blood diseases. Some doctors specialize in
chemotherapy treatments, while others focus on radiation therapy. Most doctors who specialize in oncology serve
internships and residencies that focus on cancer treatment, usually in their preferred branch of therapy. A specialist
often serves about four years beyond the normal residency period.
Oncology also involves research into cancer, its causes and possible cures. This is also a wide-open field for
scientists interested in a variety of research opportunities. Oncology researchers continue to look for ways to treat even
the rarest forms of cancer in humans.
Oncology has come a long way since early surgeons were able only to excise tumors with the most primitive
means. It has leaped forward even in the past 25 years or so, with huge improvements in prevention, diagnosis and
treatment. Doctors agree that early detection, if not prevention, is the best way to deal with cancer, and oncology also
covers this facet of medicine. From this philosophy, tests like the Prostate-Specific Antigen panel have come into being.
This test alone has saved countless men through early detection of prostate cancer or pre-cancerous conditions. Other
exams, such as mammograms, represent huge strides in the early detection and treatment of breast cancer, while the
Pap smear assists in early diagnosis of cervical cancer.

In clinical oncology, there are three primary disciplines:
 Medical oncology
 Surgical oncology
 Radiation oncology
 Pediatric oncology
Within these four primary disciplines, oncologists may and often do further specialize in specific types of cancer such
as:
 Breast cancer
 Lung cancer
 Prostate cancer
 Leukemia
 Lymphoma
 Brain and spinal cord cancer (neuro-oncology), etc.

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The physiotherapist has a very important role in encouraging the patient to remain positive and in control of their condition.

1.0 MEDICAL ONCOLOGY:
Medical oncology is the specialty of internal medicine that deals with the diagnosis and, more specifically, the
management of the treatment of cancer.
A medical oncologist is an internist who has completed a one-year internship followed by a three year residency in
oncology and internal medicine. He or she has knowledge of all aspects of the treatment of cancer including
chemotherapy, surgery, radiation therapy, and biological therapy. In practice it is the medical oncologist who determines
the proper choice of drugs and the dosage and schedule of drugs to be given. Consultation with radiation therapists and
surgeons is frequent so that chemotherapy can be combined with these modalities when it can offer the best outcome.
The medical oncologist usually is the manager of the care of a cancer patient. Expertise in pain management, the
medical oncologist considers treatment of chemotherapy side effects, psychological care, and social needs all. A
medical oncologist may have a special interest in certain types of cancer or certain therapies such as biological therapy.
But, the medical oncologist has the training, experience, and skills for finding out the latest information on all forms of
cancer and all types of therapy.

Medical oncology can only work when the strengths and expertise of numerous fields–immunology,
molecular biology, translational medicine, etc.–are leveraged in an integrated, coordinated fashion.

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2.0 SURGICAL ONCOLOGY:
quot;Surgical Oncologyquot; refers to surgery for cancer. As board certified general surgeons, we are trained in nearly all-
major organ resections for cancer.
In addition, we are aware of the options for chemotherapy and radiation therapy and whether they should be given
before or after the operation. We work closely with medical and radiation oncologists to provide you with optimal care.

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3.0 RADIATION ONCOLOGY:
Radiation oncology, also called radiation therapy or therapeutic radiology, is a specialty of medicine that uses
various forms of radiation to treat disease, especially various cancers. In contrast, diagnostic radiology employs X-rays
and other modalities for diagnostic imaging.
Radiotherapy or radiation treatment is defined as the treatment of diseases (mostly malignant) with ionizing
radiation. The various types of ionizing radiation are X-rays, gamma rays, electrons; neutrons etc. but rays and high
energy X-rays are in common practice. Ionizing radiation are capable of damaging the genetic material (DNA) in vivo
without significant deleterious effects on normal tissues. Usually, X-rays are generated from X-ray tube of a Lineal
Accelerator and rays from TeleCobalt unit. Radiation can cure or control cancer by inhibiting the cancer cells from
dividing or reproducing. About fifty to sixty percent of patients with cancer will require radiation at sometime or other
during the course of their disease. Radiation is a safe and effective form of treatment for patients of all ages.
Radiation oncology is relatively a new subject as compared to other medical specialties. However, there is no other
medical field which had more speedy evolution than radiation oncology. Within a short span, it has attained tremendous
growth and made a place for itself in the medical science showing its utility in the welfare of mankind. Almost a century
ago, Famous German physicist, Wilhelm
Conrad Roentgen discovered the X-rays on 8th November 1895. Soon after the discovery of X-rays, Henry Beqerral
in 1896 and Radium by Madame Curie discovered radioactivity in 1898. Radiation was used for treatment of cancer as
early as in 1898. Since then, the field of radiation oncology has come a long way. With growing technology and better
understanding of radiation biology, radiotherapy achieved many milestones at a faster speed. Since early 1990s,
radiation oncology has increasingly become technology oriented. This has resulted in accurate target localization and
precise delivery of radiation to the target area resulting into better tumor control, minimal normal tissue complications
and to some extent improved survival rates.

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3.1 BASIC PRINCIPLES OF RADIOTHERAPY:
An understanding of the basic principles of radiotherapy is essential to the successful use of radiation
therapy. These include:
The higher the dose of the radiation delivered to the tumor, higher the probability of the local control of the
tumor. Hence, generally the aim is to deliver the maximum dose to the tumor without causing undue toxicity to
the surrounding normal tissues. The lower the dose to the surrounding normal tissues, the lower the associated
morbidity, hence the radiation oncologists use multiple beams, optimized treatment planning, shielding,
brachytherapy and other techniques to limit the dose to the surrounding normal tissues, there by minimizing the
morbidity. Larger tumors require higher doses of radiation for control. Conversely, small or microscopic tumors
require lower doses for control. Hypoxic tumor cells (usually in he center of the tumor) are relatively radio
resistant and require higher doses of radiation to achieve cell kill. Surgical removal of the hypoxic cells
decreases the radiation dose required and increases the probability of the local control. The risk of morbidity
increases if larger volumes are irradiated. On the other hand, smaller irradiated volumes can tolerate higher
radiation doses with less potential morbidity. Hence, the aim is to minimize the volume of tissue irradiated
without missing areas harboring the tumor. Tumor cells usually proliferate faster than the normal tissues.
Shortening the time interval between surgery and radiation therapy reduces the repopulation of tumor cells.
Hence prolonged delays between surgery and start of radiation therapy should be avoided. There are basically
two types of radiation treatment:
1) External Beam Radiation Therapy (EBRT) and
2) Brachytherapy. A patient may receive one or the other, or a combination of both External Beam Radiation
Therapy (EBRT) or teletherapy denotes treatment of patient when the source of radiation lies outside the
body. The various equipments of EBRT are Linear Accelerator,

3.1.1 SIDE EFFECTS:
Because radiation is most damaging to cells that multiply rapidly, it typically affects rapidly growing
normal cells as well as the ones with cancer. Such cells are especially prevalent in the blood, hair, and
bone marrow. Damage to these and other cells can lead to a variety of side effects:
 Eating Problems: Cancer and/or radiation therapy can destroy your appetite or leave you too tired
to eat. This can become a vicious circle: Without sufficient calories, you're likely to lose weight and
become even more fatigued.
 Blood Problems: If radiation damages your bone marrow, where the red blood cells are normally
produced, you may develop anemia or bleeding problems. Production of infection-fighting white
blood cells can also be disrupted, leaving you open to disease. If your white blood cell count drops
too far, your doctor may order blood transfusions.
 Brain Swelling: Radiation therapy in your head may lead to brain swelling (edema). This swelling
can cause headaches, nausea, vomiting, seizures, and problems seeing, talking, thinking, or
walking.
 Chest Problems: If the radiation is near your lungs, you may develop a cough, either with mucus
(a quot;productivequot; cough) or without it (a quot;nonproductivequot; cough). Coughing can become severe
enough to keep you awake and lead to fatigue. You may also experience shortness of breath
(dyspnea). This problem is a frequent result of pneumonitis, an inflammation in the lung, or fibrosis,
the development of scar tissue in the lung.
 Cystitis (sis-TI-tis): Bladder infections, known medically as cystitis, are also a danger. Symptoms
include burning pain when you urinate, difficulty starting urination, a constant or sudden urge to
urinate, frequent urination at night, a decline in the amount of urine, blood in the urine, and inability
to hold urine.
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 Diarrhea: If the radiation is near your intestines, diarrhea may develop 2 to 3 weeks after radiation
begins and continue until the treatments are finished.
 Fatigue: You may feel tired during and after each treatment. (However, most people are still able to
keep working despite the fatigue.) Pain, infection, anemia, poor appetite, and depression can make
the problem worse. Fatigue can persist for weeks or months after therapy is finished, but should
eventually disappear.
 Hair Loss: You may lose some or all of your body hair during the first 2 to 3 weeks of radiation
therapy. It should start to grow back about 2 to 3 months after therapy is finished.
 Mouth Problems: The skin inside your mouth and throat may become swollen and sore and
develop a white coating of fungus called quot;thrush.quot; Don't attempt to pull this coating off; your doctor
can prescribe medicine to kill it. In addition, your saliva may become very thick and sticky, making it
hard to talk and eat, and easier to develop cavities in your teeth. Food may start to taste bad, and
you may not be able to taste some foods at all.
 Stomach Problems: You may develop nausea or vomiting if your stomach or intestines are in the
area of radiation. The attacks are usually brief, generally starting within 6 hours after radiation and
continuing for 3 to 6 hours.
 Skin Problems: The skin over the radiation area may become swollen and sore and may change
color from light pink to red to brown. It may also become itchy, dry, or flaky. If the top layers of the
skin peel off, the area may become sore and wet. Skin problems are also possible on the side of
the body where the radiation exits.
 Sexual Problems in Men: Radiation therapy can damage a man's testicles, lowering his sperm
count or causing sterility. Men may also experience difficulty getting erections. These problems are
sometimes temporary, but can also be permanent.
 Sexual Problems in Women: A woman may have the symptoms of menopause (hot flashes, no
periods) if her ovaries receive radiation, and may lose interest in sex. To reduce these side effects,
your doctor may suggest surgery to move your ovaries out of the way of the radiation.

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3.1.2 WHILE AT THE HOSPITAL EXCEPT THE FOLLOWING:
You may encounter the following procedures and equipment during your stay.
 Taking Vital Signs: These include your temperature, blood pressure, pulse (counting your
heartbeats), and respirations (counting your breaths). A stethoscope is used to listen to your heart
and lungs. Your blood pressure is taken by wrapping a cuff around your arm.
 Blood Tests: You'll need blood taken for tests before, during, and after radiation therapy. Samples
can be drawn from a vein in your hand or from the bend in your elbow.
 Blood Transfusion: If you have anemia (a shortage of red blood cells) or a low white blood cell
count, you may need a transfusion. Although you might be worried about catching AIDS or hepatitis
from tainted blood, the risks posed by going without a transfusion are actually much greater. Your
chance of receiving infected blood is about 1 in a million; severe blood loss, on the other hand, can
easily trigger a heart attack.
 Anesthesia: If you're receiving a radioactive implant, you'll need a pain-killer during the operation.
For this type of procedure, the following options are available:
 Spinal Anesthesia: This type of anesthesia requires an injection in the spine. You will be awake
during surgery but will be numb below the waist. Feeling will return in about 2 hours.
 Epidural Anesthesia: For this type, a tiny tube is positioned near the spine, allowing administration
of additional medication during the operation. You will be awake during surgery but will be numb
below the waist. Feeling will return to your legs when the anesthesia wears off.
 General Anesthesia: This alternative puts you completely to sleep throughout the operation. The
anesthetic is given either as a liquid in your IV or as a gas through a facemask or endotracheal
(END-o-TRA-kee-ull) tube placed in your mouth and throat.
 Local Anesthesia: This is simply a pain-killing injection at the site of the operation. You'll remain
awake, and may feel some painless pressure or pushing.
 Intravenous Regional Anesthesia: This approach can be used on an arm or leg. A pressure cuff is
first put on the limb, then painkillers are given through an IV. The cuff keeps the medication in the
affected limb.

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3.1.3 DURING IMPLANT SURGERY:
The doctor will make an incision close to the cancerous area, then insert into the tumor an implant
or an implant holder. The implant can take the form of a thin wire, a tube, or round marble. If a holder is
inserted, radioactive material will be added after the surgery. The operation typically takes 1 to 2 hours.

3.1.4 DURING EXTERNAL BEAM THERAPY:
The treatment schedule depends on the type of cancer, its location, and the state of your health.
Treatments can be as often as once or twice a day, 3 to 5 days a week. They can last from 2 to 8
weeks. Each treatment takes about 10 minutes, most of which time is spent positioning the radiation
beam. A beam film (also called a check or portal film) may be taken to make sure the machine is
positioned correctly. The beam causes no pain or any other sensation.

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4.0 PEDIATRIC ONCOLOGY:
Pediatric oncology is usually recognized as a fourth, distinct discipline within the field of oncology. If your child or
teen has a blood disease or cancer, a Pediatric Hematologist/Oncologist has the experience and qualifications to
evaluate and treat your child or teen. The unique nature of care of children or teens with blood diseases and cancer is
learned from advanced training and experience in practice. Pediatric hematologists/oncologists treat children and teens
from birth through young adulthood.
Pediatric hematologists/oncologists diagnose, treat, and manage children and teens with the following:
 Cancers including leukemia, lymphomas, brain tumors, bone tumors, and solid tumors.
 Diseases of blood cells including disorders of white cells, red cells, and platelets.
 Bleeding disorders.

Listed below are some definitions of words that you may hear if your child sees a Doctor or Physiotherapist

 Acute: A condition that has started suddenly (the opposite of chronic)
 Active Movements: The movements a child does with little or no help.
 Associated Movements: An increase in the stiffness of limbs due to effort
 Asymmetrical: One side of the body is different from the other, unequal.
 Bilateral: Both sides
 Chronic: A condition or symptom lasting 3 months of longer, (not an indication of severity).
 Co-ordination : Muscles working together to achieve smooth, efficient movements.
 Contracture: Permanently tight muscles and joints
 Developmental Milestone: The age at which a baby or child is expected to do certain activities, e.g. Sit, crawl, walk
 Distally: Away from the center of the body, towards the hands or feet

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 Dorsiflexion: Ankle movement, when the foot bendsupwards, towards the leg

 Eversion: Turning out (foot)

 Extension: Straightening or movement backwards of the trunk, arms and legs
 Fine Motor Skills: Activities using hands, e.g. writing, sewing
 Flexion: Bending of the trunk, arms and legs
 Floppy/ Hypotonic: Parts (or all) the body that feels loose. They can be moved in greater ranges than expected
 Gross Motor Skills: PE type activities - running, jumping etc.

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 Hypertonic: Part (or all) of the body feels stiff or tight. Spasticity is a type of hypertonia.

 Inversion: Turning in of the foot so the soles face each other, (the opposite of eversion)
 Involuntary Movements: Unintentional movements occurring without warning.
 Kyphosis: Increase rounding of the top of the back. Sometimes known as ‘humpback’

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 Lordosis: The arch in the bottom of the back, generally referred to as the ‘lumbar lordosis’

 Passive: Movements done to the child without their help or participation
 Plantegrade: The neutral position of the foot, with the ankle at a 90 0 angle.

 Plantar flexion: The movement when the ankle points downwards.

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 Prone: Lying on the tummy

 Proximal: Towards the centre of the body, the trunk, shoulders and pelvis

 Reflexes: An involuntary reaction or a utomatic postures and movements, not under the our control
 Scoliosis: A sideways curve of the spine

 Supine: Lying on the back.

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 Supination: Turning of the hand, with palm facing upwards or foot with the sole turning upwards
 Pronation: Turning of the hand, with palm facing down

 Symmetrical: Both sides equal

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 Tone: Firmness of the muscles / Readiness to move

 Valgus: The position of feet when commonly described as ‘flat’

 Voluntary Movements: Movements occurring with thought and intention

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4.1 BONES, JOINTS AND MUSCLES:
Conditions affecting bones, joints and the tissues around them are described as ‘musculo-skeletal’ or
‘orthopedics’.
Because there are many physiological and anatomical differences between children and adults, children
require a specialized approach to their orthopedic management. The physiotherapists at KidsPhysio always
consider these differences when assessing and treating children. Some of the more common musculo-skeletal
problems that affect children and teenagers include:

4.1.1 TRAUMA INJURIES:
For example fractures, sprains or strains resulting from sports, falls, car accidents and other
injuries.
 When children’s bones break they look similar to a broken green branch from a tree, hence the
name quot;greenstick fracturesquot;. Adult’s bones tend to have a well-defined break. The bones of children
and young adolescents contain quot;growing zonesquot; called growth plates or epiphyses. Special care
needs to be taken if the fracture site is near to one of these growth plates. Children often need
physiotherapy after breaking a bone to help to restore mobility and strength to the affected limb.
 Strains occur when a muscle is over-stretched, often following inadequate warming up before sport
or if the muscle is not used to a particular activity.
 Sprains are an overstretching or a partial tear of the ligaments or tendons, and are usually the
result of an injury, such as twisting an ankle or knee.

4.1.2 GAIT PROBLEMS:
When children first start walking they will often walk on their toes or with their feet turned in. This is
quite normal, but usually improves by the time they are 6 or 7. Sometimes, as children grow, they
develop an uneven walking pattern which can be improved with physiotherapy.
 Flat Feet are feet with a flattened arch. Flat feet can contribute to other problems such as knee and
hip pain and balance difficulties.
 Scoliosis is a name given to an abnormal ‘s’ shaped curve of the spine.
 Talipes is also called ‘club foot’. The ligaments and tendons around the foot and ankle are tight
when the baby is born, making the foot stiff to move. Physiotherapy stretches can help to restore
the movement in the foot.
 Erbs Palsy is also known as Brachial Plexus Paralysis. The primary nerves, that supply the
movement and sensation to the arm, are partially or completely paralyzed causing weakness and
limitation in movement. Physiotherapy helps to maximize the range of movement, strength and
function of the affected arm.
 Torticollis or ‘Wry Neck’ describes a condition where a tight sterno-mastoid muscle in one side of
the neck limits a child’s neck movements. Positioning and physiotherapy stretches can help to gain
full neck movements.
 Hyper mobility describes when a child has an increased range of movement in joints.
 Arthritis is a disease involving the immune system. It causes inflammation of joints, causing
weakness and stiffness.
 Knee Problems are common in adolescents. Osgood-Schlatter disease is an inflammation of the
bone, cartilage, and/or tendon at the top of the shinbone. Chondromalacia Patella is characterized
by pain under the kneecap.
Growing Pains are pains, generally in children’s or adolescent’s legs, often attributed to rapid growth.

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4.2 DEVELOPMENTAL DISORDERS:
Developmental pediatrics (child development) is concerned with the way children mature, from birth until
adulthood.
Physiotherapists are mainly concerned with the development of body postures and large movements (gross
motor skills). However, they need to understand the way children develop all their skills, including hearing,
speech, vision, fine movements, social behavior and play, in order to assess or treat a child with suspected
developmental problems.
Health visitors screen children for developmental problems at the 6-8 week, 8 month, 18-24 month, and 3
year checkups. If there are any concerns regarding a child’s development, if there were difficulties at birth or if a
baby is premature, they may be referred to a pediatrician (a specialist children’s consultant) at a hospital or
child development center.
If there are concerns regarding a baby’s or toddlers gross motor development, they will generally be
referred for physiotherapy. Ideally, a child should start physiotherapy as early as possible. Physiotherapy can
help babies develop from a very early age, by placing them in beneficial positions and helping them to move.
Early intervention therapy (EIT) has proven highly effective at helping improve developmental outcomes for
children with delays. High-Risk Newborns - Developmental Dysplasia of the Hip (DDH)

4.2.1 DEVELOPMENTAL DYSPLASIA:
Developmental dysplasia of the hip is a congenital (present at birth) condition of the hip joint. It
occurs once in every 1,000 live births. The hip joint is created as a ball and socket joint. In DDH, the hip
socket may be shallow, letting the quot;ballquot; of the long leg bone, also known as the femoral head, slip in
and out of the socket. The quot;ballquot; may move partially or completely out of the hip socket.
The greatest incidence of DDH occurs in first-born females with a history of a close relative with the
condition.
Hip dysplasia is considered a quot;Multifactorial trait.quot; Multifactorial inheritance means that many factors
are involved in causing a birth defect. The factors are usually both genetic and environmental.
Often, one gender (either male or female) is affected more frequently than the other in Multifactorial
traits. There appears to be a different quot;threshold of expression,quot; which means that one gender is more
likely to show the problem than the other gender. For example, hip dysplasia is more common in
females than males.
One of the environmental influences thought to contribute to hip dysplasia is the baby's response to
the mother's hormones during pregnancy. A tight uterus that prevents fetal movement or a breech
delivery may also cause hip dysplasia. The left hip is involved more frequently than the right due to
intrauterine positioning.
What are the risk factors for developmental dysplasia of the hip (DDH)?
First-born babies are at higher risk since the uterus is small and there is limited room for the baby to
move; therefore affecting the development of the hip.

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4.2.2 OTHER RISK FACTORS MAY INCLUDE THE FOLLOWING:
 Family history of developmental dysplasia of the hip, or very flexible ligaments
 Position of the baby in the uterus, especially with breech presentations
 Associations with other orthopedic problems that include metatarsus adduct us, clubfoot deformity,
congenital conditions, and other syndromes
The following are the most common symptoms of DDH. However, each baby may experience
symptoms differently. Symptoms may include:
 The leg may appear shorter on the side of the dislocated hip
 The leg on the side of the dislocated hip may turn outward
 The folds in the skin of the thigh or buttocks may appear uneven
 The space between the legs may look wider than normal
A baby with developmental dysplasia of the hip may have a hip that is partially or completely
dislocated, meaning the ball of the femur slips partially or completely out of the hip socket.
The symptoms of DDH may resemble other medical conditions of the hip. Always consult your
baby's physician for a diagnosis.
Developmental dysplasia of the hip is sometimes noted at birth. The pediatrician or newborn
specialist screens newborn babies in the hospital for this hip problem before they go home. However,
DDH may not be discovered until later evaluations. Your baby's physician makes the diagnosis of
developmental dysplasia of the hip with a clinical examination. During the examination, the physician
obtains a complete prenatal and birth history of the baby and asks if other family members are known to
have DDH.
 X-ray - a diagnostic test, which uses invisible electromagnetic energy, beams to produce images of
internal tissues, bones, and organs onto film.
 Ultrasound (Also called sonography.) - a diagnostic imaging technique which uses high-frequency
sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds
are used to view internal organs as they function, and to assess blood flow through various vessels.
 Computed tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that
uses a combination of x-rays and computer technology to produce cross-sectional images (often
called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any
part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than
general x-rays.
 Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large
magnets, radio frequencies, and a computer to produce detailed images of organs and structures
within the body.

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A. SPECIFIC TREATMENT FOR DDH WILL BE DETERMINED BY YOUR BABY'S PHYSICIAN
BASED ON:
 Your baby's gestational age, overall health, and medical history
 The extent of the condition
 Your baby's tolerance for specific medications, procedures, or therapies
 Expectations for the course of the condition
 Your opinion or preference
The goal of treatment is to put the femoral head back into the socket of the hip so that the hip
can develop normally.
Treatment options vary for babies and may include: Anatomy of the hip joint

I. PLACEMENT OF A PAVLIK HARNESS:
The Pavlik harness is used on babies up to 6 months of age to hold the hip in place, while
allowing the legs to move a little. The harness is put on by your baby's physician and is usually
worn full time for at least six weeks, then part-time (12 hours per day) for six weeks. Your baby
is seen frequently during this time so that the harness may be checked for proper fit and to
examine the hip. At the end of this treatment, x-rays (or an ultrasound) are used to check hip
placement. The hip may be successfully treated with the Pavlik harness, but sometimes, it may
continue to be partially or completely dislocated.

II. TRACTION AND CASTING:
If the hip continues to be partially or completely dislocated, traction, casting, or surgery may be
required. Traction is the application of a force to stretch certain parts of the body in a specific
direction. Traction consists of pulleys, strings, weights, and a metal frame attached over or on
the bed. The purpose of traction is to stretch the soft tissues around the hip and to allow the
femoral head to move back into the hip socket. Traction is most often used for approximately 10
to 14 days. Traction can either be set up at home or in the hospital, depending upon your
baby's physician, hospital, and the availability of the resources.

III. SURGERY AND CASTING:
If the other methods are not successful, or if DDH is diagnosed after the age of 2 years, surgery
may be required to put the hip back into place manually, also known as a quot;closed reduction.quot; If
successful, a special cast (called a spica cast) is put on the baby to hold the hip in place. The
spica cast is worn for approximately three to six months. The cast is changed from time to time
to accommodate the baby's growth and to ensure the cast's rigidity, as it may soften with daily
wear.
The cast remains on the hip until the hip returns to normal placement. Following casting, a
special brace and physical therapy exercises may be necessary to make the muscles around
the hip and in the legs stronger.

IV. SHORT LEG HIP SPICA CAST:
Anatomy of the hip joint
A short leg hip spica cast is applied from the chest to the thighs or knees. This type of cast is
used to hold the hip in place after surgery to allow healing.
 Cast care instructions:
 Keep the cast clean and dry.

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 Check for cracks or breaks in the cast.
 Rough edges can be padded to protect the skin from scratches.
 Do not scratch the skin under the cast by inserting objects inside the cast.
 Use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot,
itchy skin. Never blow warm or hot air into the cast.
 Do not put powders or lotion inside the cast.
 Cover the cast during feedings to prevent spills from entering the cast.
 Prevent small toys or objects from being put inside the cast.
 Elevate the cast above the level of the heart to decrease swelling.
 Do not use the abduction bar on the cast to lift or carry the baby.

VI. WHEN TO CALL YOUR BABY'S PHYSICIAN:
Contact your baby's physician or healthcare provider if your baby develops one or more of
the following symptoms:
 Fever
 Increased pain
 Increased swelling above or below the cast
 Drainage or foul odor from the cast
 Cool or cold toes
Long-term outlook for a baby with developmental dysplasia of the hip (DDH):
While newborn screening for DDH allows for early detection of this hip condition, starting
treatment immediately after birth may be successful. Many babies respond to the Pavlik
harness, traction, and/or casting. Additional surgeries may be necessary since the hip
dislocation can reoccur as the child grows and develops. If left untreated, the baby may have
differences in leg length, and may limp.

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4.3 BRAIN & NERVOUS SYSTEM:
The nervous system is extremely complicated. The brain has often been likened to a central computer
within a vast, complicated network of wiring (the nervous system). The brain works at lightening speed making
infinite decisions that affect the outcome of everything we do. It allows us to breathe, feel, talk, learn and
remember, and enables us to move our bones and muscles in complicated yet coordinated ways. The brain
allows us to perform all of these things and more, often without any conscious effort on our part, and even while
we are asleep.
Unfortunately, such an amazing and complex system can go wrong. Damage can happen to the brain and
nervous system before, during and after birth. Physiotherapy can help when damage occurs by helping the
brain learn or relearn patterns of movement. Some of the children’s conditions treated by physiotherapists
include:

4.3.1 CEREBRAL PALSY (CP):
Is a condition primarily affecting a child’s motor development. It is caused by damage to the brain
before, during or shortly after birth.
 Meningitis and Encephalitis are inflammatory conditions affecting the brain and spinal cord, usually
caused by bacteria or viruses. Meningitis is the inflammation of the coverings (‘meninges’) of the
brain and spinal cord. Encephalitis is an inflammation of the brain tissue itself. Both conditions can
result in permanent damage to the brain.
 Spinal Cord Injury is caused by damage to the spinal cord. It can be caused from a direct injury to
the cord itself or from an indirect injury from damage to the bones, soft tissues, and blood vessels
surrounding the spinal cord. Only about 5% of spinal cord injuries occur in children. Symptoms of a
spinal cord injury vary depending on the location and severity of the injury. The main problem is
weakness of muscles and loss of sensation at and below the level of the injury.
 Spina bifida is a congenital disorder affecting the formation of the spine. About 75% of cases are
called ‘Myelomeningocele’. The backbone and spinal canal do not completely form before birth
causing a decrease or lack of function of the parts of the body controlled from or below the defect.
Most defects occur in the lower lumbar or sacral areas of the back (the lowest areas of the spine)
because this area is normally the last part of th e spine to close during inter-utero development.

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Physical therapy is considered one of the mainstay therapies for cerebral palsy treatment. It is
used to decrease spasticity, strengthen underlying muscles, and teach proper or functional motor
patterns. A good physiotherapist will also teach the family and caregivers how to help the patient to
help themselves.
Cerebral palsy physiotherapy generally consists of a few types of physical therapy. Physical
therapy helps a cerebral palsy physiotherapy patient to improve their gross motor skills. Gross
motor skills are those that utilize the large muscles in the body, such as those in the arms and legs.
This cerebral palsy physiotherapy can help improve a patient's balance and movement.
Learning to walk, stand without aid, use a wheelchair or other adaptive equipment, and other
movement skills can be greatly improved with cerebral palsy physiotherapy. Physical therapists
help prevent further development of musculoskeletal problems in cerebral palsy physiotherapy
patients.
They do this by preventing muscle weakening, deterioration, and contracture through proper
cerebral palsy physiotherapy techniques. pressurized tank, can restore function to nerve cells that
border the area of brain damage, rejuvenating them to a functional degree.
Unfortunately, all of these treatments are not available everywhere, nor are they necessarily
going to be effective in each and every case of cerebral palsy treatment. Consult with your doctors
and therapists, talk to people who have tried the treatment, and do your own research as well
before deciding what cerebral palsy treatment is right for your child.
Cerebral palsy physiotherapy can start soon after diagnosis, and treatment is often more
successful with early intervention.

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4.3.2 HEAD INJURIES:
Head injuries are injuries to the brain caused by the head being hit by something or shaken violently.
Head injuries are also called traumatic head or brain injury (TBI) and acquired brain injury (ABI). They
can change how the person acts, moves and thinks. The signs of head injury can be very different
depending on which part of the brain has been injured and how severely.
 Microcephaly is a neurological disorder where the baby’s head is much smaller than normal for an
infant of the same age and sex. It may be associated with other conditions or syndromes. Children
with microcephaly may have learning difficulties and delayed development.

A. CAUSES OF MICROCEPHALY MAY INCLUDE:
 Fetal alcohol syndrome
 Decreased oxygen to the fetal brain (cerebral anoxia) due to pregnancy complications or
complications during delivery
 Craniosynostosis — the premature fusing of the joints (sutures) between the bony plates that
form an infant's skull

 Chromosomal abnormalities

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 Infections of the fetus during pregnancy, such as toxoplasmosis, cytomegalovirus, German
measles (rubella) or chickenpox (varicella)

In most cases, there's no specific treatment for microcephaly. Treatment is usually directed at
managing the signs and symptoms associated with the disorder. If microcephaly due to
craniosynostosis is detected early, treatment may include surgical opening of the sutures to let the brain
grow normally.
If you're concerned about the size of your child's head, talk to your doctor. Doctors use growth rate
charts — similar to those for height and weight — to compare your child's head circumference with that
of other children of the same age and sex.
It's important to note that heads with circumferences in the 3rd, 2nd and even 1st percentiles are
just small heads. Microcephaly is a head circumference that is significantly below the 1st percentile.

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4.4 SYSTEM & LUNG:
Conditions that affect the whole body are called ‘systemic conditions’. Examples include chronic fatigue
syndrome, lupus and systemic juvenile arthritis. Specific and graded exercise programs have been shown to
help the recovery of such problems. Respiratory conditions effect the lungs and air passages. Physiotherapist
offers assessment, treatment and advice on respiratory conditions including asthma and cystic fibrosis.

4.4.1 CHRONIC FATIGUE SYNDROME:
(CFS) is a condition that causes severe fatigue, which interferes with a person’s normal life? It
used to be known as ME (myalgic encephalomyelitis).
It can affect any age group including school children and the elderly, but it most commonly affects
teenagers and young adults.
In the past, doctors believed that chronic fatigue syndrome (CFS) was related to depression and
that the symptoms were quot;all in the mindquot;. Whilst the condition remains poorly understood, most experts
now agree that it is a distinct disease with physical symptoms. There are several hypotheses for the
cause of CFS:
 CFS may develop following a viral or bacterial infection, for example glandular fever. (It is not the
same as the normal fatigue that often follows a bad infection like flu.)
 It may be linked to disorders that affect the body’s natural defenses (the immune system) or to
abnormalities of the hormonal system or the nervous system.
 Some doctors believe that there is a strong psychiatric or psychological element to CFS, and that
some cases it may be a form of depression. It may follow distressing life events such as
bereavement.
The main symptom of CFS is severe fatigue that lasts for over six months and does not improve
after rest. People who have CFS may also have other symptoms such as:
 Forgetfulness, memory loss, confusion, or difficulty concentrating
 Sore throat,
 Ender lymph nodes in the neck or armpits,
 Muscle pain,
 Joint pain without redness or swelling,
 Headaches,
 Unrefreshing sleep (waking up feeling tired or unrested) or trouble getting to sleep,
 Fatigue that lasts more than 24 hours after exercise or exertion at a level that the person was
previously able to manage without fatigue,
 Feeling hot or feverish even though temperature may be normal,
 Sensitivity to light or sound,
 Light-headedness or dizziness, when standing or sitting up from lying.
There is no specific test for diagnosing Chronic Fatigue Syndrome. It is usually diagnosed by using
the history of symptoms and ruling out other possible conditions. When a doctor examines someone
with CFS they usually find no abnormalities with their physical examination or blood tests.
Unfortunately, there is no simple cure for CFS. Most people who have CFS find that their symptoms
get better over time and they are able to resume normal daily activity within 1 to 2 years. Some people
will continue to have symptoms for many years.
KidsPhysio may be able to help by providing advice regarding appropriate exercise. We can look at
your routines: including sleep patterns, which activities you are able to do / enjoy doing and what makes
your symptoms better or worse. We will then discuss appropriate exercise, where possible, in the form
of everyday activities, for example shopping, walking up and down stairs. Often specific strengthening
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