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Orthopedic Manual Therapy for the Pediatric Patient
Mitchell Selhorst, DPT, OCSNationwide Children’s Hospital Sports and Orthopedic PT
Columbus, Ohio
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Learning Objectives
The attendee will:• Understand the specific precautions and the
relative risk of performing orthopedic manual therapy on pediatric patients.
• Identify pediatric patients who are appropriate for orthopedic manual therapy.
• Use orthopedic manual physical therapy to minimize pain and maximize function in pediatric orthopedic patients.
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Pediatric Physical Therapy
This is the Pediatric I Mean
Kids Need PT Too!
Pediatric Pain is Not Benign
• Injury in childhood may lead to increased risk of pain in adulthood.23
• Pain does not go away on its own– 2/3 of adolescents with low back pain will
have chronic or recurrent symptoms 6 months later.38
Clinical Practice Guidelines Recommend use of Manual Therapy
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Alright, Let’s Do Manual Therapy!
Growing Children
Wait…
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Contraindications and Precautions• Contraindication: A circumstance which
absolutely rules out the use of a therapeutic method which would otherwise be indicated.
• Precaution: The risks of a treatment have to be carefully assessed before treatment is initiated, and it can only be administered if its benefits to the patient are greater than its risks
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Why are Children a Precaution for Manual Therapy?
Controversial: Not all authors agree that a growing child is a precaution.• Growth plates and cartilage endplates• Ability to give informed consent• Lack of research
Growth and Cartilage End Plates
Growth Plates Age of Ossification
Wrist 17‐19 years
Elbow 15‐18 years
Shoulder 19‐25 years
Hip 18‐25 years
Knee 19‐25years
Foot and Ankle 18‐20 years
Females 1-2 years sooner than males
End Plates Age of Ossification
Cervical 16‐18 years
Thoracic 16‐18 years
Lumbar 16‐18 years
Sacrum 18‐25 years
Forces of Manual Therapyvs Normal Activity
<
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What is the Risk MT will damage a growth plate?
• Unknown: No documented case of growth plate injury has occurred due to manual therapy.– 10,000,000 manual therapy interventions
performed on children every year.– 2.3 million performed in the US alone.31
Gaining Informed Consent from a Child
• A minor cannot provide informed consent• Discussion of the risks and benefits of
manual therapy becomes a family discussion
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Risks from Lack of Research
• Children are not tiny adults, many research results are not generalizable.
• We don’t know what we don’t know
Children are Not Tiny Adults
I have hair
< 50% Non-Specific LBP
90% Non-Specific LBP
Remains Active
Skeletally Mature
Growth PlatesAvoids Activity
????????
????
I wish I had hair
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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 conservative
management
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Rely on your Red Flags
• Persistent pain• Increases at rest• Progressive neurological deficits• Associated fever• Night pain• Bowel or bladder incontinence
Ruling out Fractures
• Ottawa Ankle Rules28
• Ottawa Knee Rules37
• Canadian C-Spine Rules
OK!
OK!
STOP!
-Patients >10 years12
-Patient < 10 years12
OK!
Not Sensitive Enough
Can we use CPR’s to guide manual 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 IR motion in children
Can we use a Modified CPR for Lumbar Manipulation
Patient meets 3 out of the 4– Pain for <16 days– No pain distal to the knee– 1 Lumbar segment hypomobile– Hip IR >35 degrees
In a RCT assessing lumbar manipulation in adolescents, only 5% met either of these modified rules. Unable to assess the effectiveness of these CPR’s.38OR
Patient have both of the following-Pain for <16 days-No pain distal to the knee
How to Identify Appropriate Patients for Manual Therapy
Does the clinician think the patient would benefit from MT?
Manual Therapy Not Appropriate
Contraindications?
Do risks outweigh the benefits?
Trial MT
Positive Outcome.Continue as Indicated
Yes
Yes
No improvement
No
No
No Yes
Case of Low Back Pain
13-year-old female – 2-month hx of LBP– Insidious onset – Has not improved over
past 4 weeks– No report of pain, NT, or
weakness in LE’s– No red flags noted during
evaluation
Case of Low Back Pain 13-year-old female with 2-month hx of LBP
-Recreational dancer (Hip Hop and Ballet) 4 hours of class a week.-Pain is worse with activity(2/10 at rest 6/10 pain during dance)-Pain increases by 2/10 with lumbar extension-Scored a 14/30 on Patient Specific Functional Scale
Dance 4/10Bending backwards 5/10Walking for >20 minutes 5/10
Should We Utilize Manual Therapy with this Patient?
Treatment Consideration for the pediatric lumbar spine
• Much of pediatric back pain has an anatomical cause, some can be precautions or contraindications to manual therapy
• Up to 50% of adolescent athletes with low back pain have a spondylolysis or spondylolisthesis.43
SpondylolysisType Name Pathogenisis
Type I Dysplastic Congenital abnormalities
Type II Isthmic Stress fracture in the pars interarticularis
Type III Degenerative Degeneration of the intervertebraldiscs
Type IV Traumatic Acute fracture in areas other than pars
Type V Pathological Bone disease, tumor, or infection
Grades of SpondylolisthesisGrade of ‐listhesis % Slippage of the
vertebral bodyGrade I 1‐25%
Grade II 26‐50%
Grade III 51‐75%
Grade IV 76‐100%
Pediatric Spondylolytic Injury
Acute Lesion Chronic Lesion Lesion with anterolisthesis
Increased uptake (SPECT) or edema (MRI) noted in the symptomatic region
Active fractureManual Therapy is
contraindicated in region
Lesion diagnosed but no signs of active healing noted on imaging
Fibrous lesion, unlikely to achieve bony union. Manual Therapy is a
precaution
Grade I‐IV Can be determined by
X‐ray, CT, MRI
Precaution or Contraindication
Depending on Grade and stability of ‐listhesis
Are there contraindication for manual therapy?
13-year-old female with 2-month hx of LBP
– ImagingX-ray - NegativeMRI - Negative
Risk and Benefits of Manual Therapy with this Patient?
• Physical therapy, including manual treatment, results in significantly better outcomes in children with back pain.1
• Lumbar manipulation does not increase risk of an adverse event in adolescents with non-specific low back pain.38
Trial Manual Therapy!
A Case of Neck Pain9-year-old male injured his neck 3 days ago while tackling in youth football.
– Current patient (left shoulder)– Reports 7/10 right mid-
cervical pain– No report of numbness or
tingling– Significant TTP of R C3-4
A Case of Neck Pain
9-year-old male injured during youth football
– Patient maintained consciousness– Not a helmet-to-helmet collision – Active cervical ROM
Flexion 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 Manual Therapy with this Patient?
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Are there contraindications for 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 Shoulder
• Clinical diagnosis of secondary GH impingement and multi-directional instability.
• Generalized hypermobility notedBeighton score of 6 out of 9
11-year-old female with R shoulder pain
A Case of Swimmers Shoulder
+ Hawkins-Kennedy+ Painful Arc+ ER weakness+ Excessive anterior
GH joint laxity+ Sulcus sign- Apprehension
11-year-old female with R shoulder pain
Should We Utilize Manual Therapy with this Patient?
Are there contraindications for manual therapy?
Generalized Hypermobility is considered a precaution by most, a few consider it a contraindication.
– When treating a patient with hypermobility, the therapist should examine opposite motions and neighboring segments to find out if any restrictions exist.
Risks vs Benefits
• Risks: Manual therapy done incorrectly could increase the patient’s hypermobility and multi-directional instability.
• Benefits: Restoring motion to neighboring segments could improve proper GH joint mechanics- 2 case studies support this theory.7, 27
Trial Manual Therapy
Target restricted areas:– Posterior Shoulder– Pec Minor– Thoracic Extension– Scapular thoracic
A Case Acute Ankle Sprain
– 5-days post injury
– Does not participate in sports
– Fell off obstacle course and rolled his ankle
– No imaging performed
– Presents to clinic on crutches and ACE wrap
15-year-old male with L inversion ankle sprain
A Case of Acute Ankle Sprain
– Patient is able to walk in clinic without use of crutches with antalgic gait
– TTP at ATFL – Talar Tilt, Anterior drawer + (pain)– No tenderness at medial/lateral
malleoli, navicular or base 5th
metatarsal– Mild swelling noted upon visual
examination
15-year-old male with L inversion ankle sprain
Should We Utilize Manual Therapy with this Patient?
Are there contraindications for manual therapy?
• Rule out fracture with the Ottawa Ankle Rules.
• No other precautions or contraindications noted
Risks vs Benefits
Risks: Minimal. No adverse reaction noted in research for this population
Benefits: Short and long-term benefits noted with use of manual therapy for acute ankle sprain.44, 45
Trial Manual Therapy!
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Conclusion• Manual therapy can be an effective way to
minimize pain and maximize function in pediatric orthopedic patients.
• Weigh the risks and benefits before proceeding
• Rely on patient history, your clinical expertise, and the patient’s preference until there is better research to guide EBP.
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