Chapter 30. Special Populations

At the completion of this chapter, the reader will be able to:

1. Discuss the physical therapy role with a variety of orthopaedic subtypes and the challenges each presents.

2. Describe the various pathologies for these populations in terms of the presentation and the role that physical therapy plays.

3. Outline the differences between a congenital condition and an acquired condition.

4. Describe the normal aging process as it relates to orthopaedics.

5. Outline the various theories of aging.

6. Describe the common pathological conditions and functional limitations associated with the geriatric population.

7. Describe some of the conditions that can affect women's health.

8. Describe the physiologic changes that occur during pregnancy within the various bodily systems.

9. Describe the physical therapy interventions for pregnancy-related dysfunctions.

10. Describe the complications related to breast-cancer-related lymphedema.

There are a number of population subtypes that require special consideration in terms of the orthopaedic examination and intervention. These include pediatrics and geriatrics, and the whole spectrum of women's health. Each of these populations is described in this chapter.

The term pediatric refers to the 0- to 21-year age range during which an individual undergoes many changes while aging, evolving, and maturing. During the preschool years, physical growth, neurologic growth, and maturation are quite rapid and apparent, with new skills being acquired at a quick pace.1 This process continues throughout the middle years (ages 6–11) at a somewhat slower pace. As a child enters puberty, rapid development of physical and sexual characteristics become more apparent and is accompanied by important psychosocial development. It is important to remember that chronologic age does not necessarily correlate well with many physiologic and somatic changes.

The major characteristics of somatic and skeletal growth and maturation during adolescence are outlined in Table 30-1. In addition, the following differences exist between the adult and the pediatric patient:2

• Cardiovascular system. The pediatric heart is smaller than that of the mature adult, resulting in a smaller capacity as a reservoir for blood, and thus a lower stroke volume at all levels of exercise, which is compensated for with an increased heart rate. As with the adult patient, systolic blood pressure rises during exercise in the pediatric patient, but the elevation is less. Finally, the thoracic cavity is obviously smaller in the younger child than that of the mature adult, resulting in the pediatric patient demonstrating a smaller vital capacity than the adult and an elevated resting respiration rate.3 The red blood cell count for young boys and girls are similar with comparable abilities to carry oxygen to exercising organs. After menarche, however, females demonstrate lower blood volume and fewer red blood cells with a resultant decreased oxygen carrying capacity and a lower mean blood pressure.4 These differences result in the following responses to exercise in the pediatric patient:
  • Until 12 years, absolute maximal oxygen uptake (VO2max) values increase at the same rate in both genders, although boys have higher values as early as 5 years. VO2max increases concomitantly with growth until 18 years in boys and 14 years in girls.
  • The pattern of relative magnitudes of cardiovascular and ventilatory responses to progressive and sustained dynamic exercise appears to be qualitatively similar between adults and children.
  • Children rely more on oxidative rather than anaerobic metabolism compared to adults.
  • Children demonstrate greater energy expenditure during weight-bearing activities such as running and walking compared to adults.
• Musculoskeletal system. Young children possess muscle fiber numbers, types, and distribution similar to that of adults. There is an increase in muscle hypertrophy during adolescence as a result of increased androgens. In addition, agility, motor coordination, power, and speed also show improvement during adolescence. There are a number of structural differences between the adult and pediatric patient:
  • In the adolescent, growth cartilage is present at the epiphyseal plate, the joint surface (articular cartilage), and the apophysis. The epiphyseal plate or growth plate is divided into zones differentiated from one another via structure and function (see Chap. 1). Growing bone is the weak musculoskeletal link in the young athlete. Similar physical demands that can result in muscle strain or ligament sprain in the skeletally mature patient may result in an epiphyseal plate injury in a young patient. Two factors that impact epiphyseal plate injury are (1) the ability of the growth plate to resist failure and (2) the forces applied to bone or the stresses induced in the growth plate. The majority of epiphyseal fractures are due to high-velocity injuries.
  • A certain amount of load is necessary for normal bone growth and remodeling. In most long bones, epiphysis is at least partially ossified at an early age. However in certain areas of the body (e.g., ischial tuberosity, iliac crest, base of the fifth metatarsal), the epiphysis may not become ossified until the near end of the final growth spurt. Most of the bone mineral density is acquired during the adolescent years and bone mass may fail to accrue optimally because of dieting and weight loss. Because the strength development of bones lags behind that of ligaments and tendons, there is an increased risk of tendon or bone avulsion at the apophyseal insertion compared to a ligament injury.

Examination of the Pediatric Patient

In addition to the areas typically covered in the orthopaedic examination outlined in Chapter 4, a number of additional factors must be considered in the pediatric population. For example, when taking the history of a pediatric patient, the clinician should pay particular attention to the following:2

• Current life circumstances. The pediatric patient's current health, attitudes and values of the child's immediate family, and acculturation of the patient.
• Gender. Females and males develop differently, particularly during adolescence (Table 30-2).
• Health history. Health and nutrition history, repeated hospitalizations, and so on.
• Developmental history.T he pediatric patient's past rate of achievement of developmental milestones, events that might have had profound effects on the patient either physically or psychologically.
• Extrapersonal interactions. The reaction of the pediatric patient to the treating clinician and the conditions under which the pediatric patient is observed.
• Age-related changes in muscle and muscle performance.
• The developing skeletal system. Examination of the pediatric patient requires an understanding of, and an awareness of, the timing of growth center appearance and epiphyseal closure. For example, the sequence and average timing of growth center appearance at the elbow are as follows5:
  • Capitellum. Female, 4 months; male, 5 months.
  • Medial epicondyle. Female, 5 years; male, 7 years.
  • Trochlea. Female, 8 years; male, 9 years.
  • Lateral epicondyle. Female, 11 years; male, 12 years.

Epiphyseal closure at the elbow occurs sequentially, first in the distal humerus, with the capitellum, lateral epicondyle, and trochlea fusing together at puberty (female, 14 years and male, 17 years), then fusing with the shaft.5 The medial epicondyle fuses later (female, 15 years and male, 18 years). The radial head and olecranon close at 14 years in females and 15 years in males.5

Growing musculoskeletal tissue is innately predisposed to specific injuries that vary greatly from injuries sustained by their skeletally mature counterparts. Most of this growth occurs in two phases from birth to adulthood. There is a rapid gain in growth in infancy and early childhood that slows down during middle childhood. The second rapid increase in growth occurs during adolescence. An injury that occurs during one of these phases, which is significant enough to interrupt the growth process, can present serious challenges.

Skeletal Fracture

The mechanical properties and healing qualities of skeletal bone are described in Chapters 1 and 2, respectively. In the pediatric population, the metaphysic–physis junction is an anatomic point of weakness. Fractures of bone in pediatric patients may be due to direct trauma, such as a blow, or indirect trauma, such as a fall on the outstretched hand (FOOSH injury), or a twisting injury. Three types of fractures occur more commonly in the pediatric population:

• Greenstick. A type of simple fracture in which only one side of the bone is fractured while the opposite side is bent. Because the bones in a pediatric patient have not fully developed, they are less rigid and brittle. This type of fracture tends to heal faster than other types.
• Avulsion. Avulsion occurs when a piece of bone attached to a tendon or ligament is torn away. In the younger population, ligaments and tendons are stronger than bone. When changes in muscle length do not match the changes in long-bone growth, tensile loads placed within the muscle predispose the pediatric patient to injury. Lower extremity avulsion fractures outnumber avulsion fractures of the upper extremity. Common sites of avulsion fracture in the lower extremity include the anterior superior iliac spine (ASIS), anterior inferior iliac spine (AIIS), ischial tuberosity, and the base of the fifth metatarsal. Common sites of avulsion fracture in the upper extremity include the medial humeral epicondyle and the proximal humerus. If a medial epicondyle avulsion fracture is suspected, it is important to assess the ulnar nerve, and for the presence of point tenderness of the medial epicondyle, swelling, ecchymosis, and valgus instability.
• Growth plate (physeal). This type of fracture may be defined as a disruption in the cartilaginous physis of long bones that may or may not involve epiphyseal or metaphyseal bone. Injuries to the physes are more likely to occur in the pediatric population, in part due to the greater structural strength and integrity of the ligaments and joint capsules than of the growth plates and the fact that the physes of an adult have ossified. Growth plate fractures can have severe consequences because of the potential for growth plate closure, which inhibits future growth resulting in limb length discrepancies. Conversely, an injury near, but not at, the physis can stimulate increased bone growth.

The Salter and Harris classification is the preferred and accepted standard in North America for classifying physeal fracture patterns:3

• Type I. This occurs due to shearing forces in which there is complete separation of the epiphysis without fracture of the bone. These fractures are most commonly seen in the very young patient when the epiphyseal plate is relatively thick.
• Type II. This is the most common type of growth plate fracture resulting from shearing and bending forces. The line of separation traverses a variable distance along the epiphyseal plate and then makes its way through a segment of the bony metaphysis that results in a triangular-shaped metaphyseal fragment.
• Type III. This typically results from shearing forces and results in intra-articular fractures from the joint surface to the deep zone of the growth plate and then along the growth plate to its periphery. These fractures are typically limited to the proximal tibial/distal femoral epiphysis and can result from valgus loading of the knee, which is frequently encountered in contact and collision sports.
• Type IV. These are intra-articular fractures that result from shearing forces. These fractures extend from the joint surface to the epiphysis across the entire thickness of the growth plate and then through a segment of the bony metaphysis.
• Type V. These types of fractures, which are due to a crushing mechanism, are relatively uncommon.

Clinical Findings

The most common clinical presentation with a pediatric fracture is pain, weakness, and functional loss of the involved area. The most common areas for epiphyseal fracture include the distal radius and the medial epicondyle, the proximal humerus, and the proximal tibia/distal femoral.

Intervention

In most cases, the medical management of a fracture involves immobilization through casting, splints, or surgical fixation to allow full healing to occur. Pediatric fractures tend to heal faster than an equivalent one in an adult. This can be advantageous: Children typically require shorter immobilization times. A disadvantage, however, is that any malpositioned fragments become immovable or fixed much earlier than in adults (3– 5 days in a young child, 5– 7 days in an older child, as opposed to 8–10 days in an adult). However, the normal process of bone remodeling in a child may correct malalignment, making near-anatomic reductions less important in children than in adults. Remodeling can be expected if the patient has two or more years of bone growth remaining. Rotational deformity remodels poorly, if at all, and is therefore corrected by surgical reduction. A further complication is that pediatric fractures may stimulate longitudinal growth of the bone, making the bone longer than it would have been had it not been injured. This is particularly true for fractures of the femoral or tibial shaft.

Children tolerate prolonged immobilization much better than adults, and disabling stiffness or loss of range of motion (ROM) is distinctly unusual after pediatric fractures. Physical therapy, if needed, typically begins after the immobilization period, and depending on the type and location of the fracture, it can involve any or all of the following:

• Pain management techniques including the use of noncontraindicated electrotherapeutic modalities (see Chap. 8) and manual techniques, including joint mobilizations.
• ROM exercises, following the hierarchy of progression outlined in Chapter 13.
• Strengthening exercises, beginning with isometrics and progressing using the hierarchy of progression outlined in Chapter 12.
• Gait and/or crutch training with an appropriate assistive device and following the prescribed prescription for weight bearing (see Chap. 6).
• Proprioception exercises for balance and coordination (see Chap. 14).
• Functional training including adaptive, supportive, or protective devices and activities of daily living (ADLs) and self-care.
• Patient and family education to decrease the risk of re-injury and to promote healing.

Juvenile Rheumatoid Arthritis

Juvenile rheumatoid arthritis (JRA) is a group of diseases that are manifested by chronic joint inflammation8,9. The exact etiology of JRA is unclear, but the prevailing theory is that it is an autoimmune inflammatory disorder, activated by an external trigger, in a genetically predisposed host. JRA is defined as persistent arthritis, lasting at least 6 weeks, in one or more joints in a child younger than 16 years of age, when all other causes of arthritis have been excluded. The clinical findings and manifestations of JRA are outlined in Chapter 5.

A detailed physical examination by a physician is a critical tool in diagnosing JRA to help rule out other causes. Medical care of children with JRA must be provided in the context of a team-based approach, considering all aspects of their illness (e.g., physical functioning in school and psychological adjustment to disease).

Intervention

Physical therapists are essential members of the rheumatology team that includes the rheumatologist, nurse, occupational therapist, ophthalmologist, orthopedist, and pediatrician.10 Other specialists, including cardiologists, dermatologists, orthotists, psychologists, and social workers, provide occasional consultation as needed. The physical therapy examination is performed to determine the relationship between the impairments and observed or reported activity restrictions. The plan of care (POC) is designed to reduce current impairments, maintain or improve function, prevent or minimize secondary problems, and provide education and support to the child and family. Specific interventions can include any or all of the following:

• ROM and stretching exercises.
  • Acute stage: passive and active assisted to avoid joint compression.
  • Subacute/chronic stages: active exercises.
• Strengthening: avoid substitutions, minimize instability, atrophy, deformity, pain, and injury.
  • Acute and subacute stages: isometric exercises progressing cautiously to resistive.
  • Chronic stage: concentric exercises.
• Endurance exercises: encouraging exercise by using fun and recreational activities, swimming.
• Joint protection strategies and body mechanics education.
  • Mobility assistive devices.
  • Rest, as needed—balance rest with activity by using splinting (articular resting).
  • Posture and positioning to maintain joint ROM.
  • Patients should spend 20 minutes/day in the prone position to stretch the hip and knee flexors
  • Avoidance of high-impact activities.
  • Assess leg length discrepancy in standing and avoid scoliosis.
• Therapeutic modalities for pain control.
• Instructions on the wearing of warm pajamas, sleeping bag, electric blanket.

Idiopathic Scoliosis

The overall contour of the normal vertebral column in the coronal plane is straight. In contrast, the contour of the sagittal plane changes with development (see Chap. 22) 11–24. Scoliosis represents a progressive disturbance of the intercalated series of spinal segments that produces a three-dimensional deformity (lateral curvature and vertebral rotation) of the spine. Despite an extensive amount of research devoted to discovering the cause of idiopathic scoliosis, the mechanics and specific etiology are not clearly understood, hence the name. It is known, however, that there is a familial prevalence of idiopathic scoliosis.

Clinical Findings

Using the James classification system, scoliosis has three age distinctions. These distinctions, though seemingly arbitrary, have prognostic significance.

• Infantile idiopathic. Children diagnosed when they are younger than 3 years, usually manifesting shortly after birth. Although 80–90% of these curves spontaneously resolve, many of the remainder of cases will progress throughout childhood, resulting in severe deformity. In the most common curve pattern (right thoracic), the right shoulder is consistently rotated forward and the medial border of the right scapula protrudes posteriorly.
• Juvenile idiopathic. Children diagnosed when they are 3–9 years. This type is found more frequently in girls than boys, and individuals that develop this condition are generally at a high risk for progression to more severe curves.
• Adolescent idiopathic. Manifesting at or around the onset of puberty and accounting for approximately 80% of all cases of idiopathic scoliosis.

The following are the main factors that influence the probability of progression in the skeleton of the immature patient:

• The younger the patient at diagnosis, the greater the risk of progression.
• Double-curve patterns have a greater risk for progression than single-curve patterns.
• Curves with greater magnitude are at a greater risk to progress.
• Risk of progression in females is approximately 10 times than that of males with curves of comparable magnitude.
• Greater risk of progression is present when curves develop before menarche.

Scoliosis is generally described by the location of the curve or curves. One should also describe whether the convexity of the curve points to the right or left. If there is a double curve, each curve must be described and measured. As the disease progresses, the spinous processes of the vertebrae in the area of the major curve rotate toward the concavity of the curve. On the concave side of the curve, the ribs are close together. On the convex side, they are widely separated. As the vertebral bodies rotate, the spinous processes deviate more and more to the concave side and the ribs follow the rotation of the vertebrae. The ribs on the convex side are rotated more posteriorly, causing the characteristic rib hump seen in thoracic scoliosis. The ribs on the concave side are rotated more anteriorly. Because the onset and progression of scoliosis (until skeletal maturity) are generally asymptomatic, it can develop undetected without close examination.

The significant incidence of scoliosis in the adolescent population has prompted the creation of school screening programs in all 50 states. Visual observation is used during the Adam's forward bending test, which involves asking the patient to bend forward at the waist as though touching his or her toes while the clinician, who is standing behind the patient, looks along the line at the back and determines whether one side is higher than the other. If scoliosis is suspected, the magnitude of a rib hump is quantified by placing a scoliometer (an inclinometer) over the spinous process at the apex of the curve during the Adam's forward bending test to measure the angle of trunk rotation as the patient bends forward. During the physical examination by the patient's physician, a determination is made as to whether the deformity is structural (cannot be corrected with active or passive movement and there is rotation toward the convexity of the curve) or nonstructural (fully corrects clinically and radiographically with trunk side bending toward the apex of the curve and lacks vertebral rotation). Nonstructural scoliotic curves can result from length–length discrepancies, muscle disuse/overuse, habitual postures, and muscle guarding.

Height measurements are taken in sitting and in standing. Changes in sitting height can be less than changes in standing height and give a better estimate of truncal growth rate. Trunk compensation is typically assessed using a plumb-line, and a radiographic leg length measurement is also obtained.

Skeletal maturity is determined using the Risser sign, which is a measurement of the progressive ossification from anterolaterally to posteromedially in the iliac apophysis. Once a child reaches a Grade 5 on the Risser scale, his or her scoliotic curve will stabilize. A child with idiopathic scoliosis usually progresses from a Risser grade 1 to a grade 5 over a 2-year period.

Most curves can be treated nonoperatively through observation with periodic radiographs to check for the presence of curve progression. However, approximately 60% of curvatures in rapidly growing prepubertal children typically progress, and may require bracing (Boston, or custom thoracolumbosacral orthosis) or surgery.

Intervention

Physical therapy intervention for scoliosis is based on the skeletal maturity of the child, the growth potential of the child, and the magnitude of the curve. The primary benefits of exercise in a nonsurgical patient with scoliosis are as follows:25

• Help with correct postural alignment and any asymmetrical postural habits to prevent further development following the bracing program.
• Maintain proper respiration and chest mobility.
• Improve overall spinal mobility and to help reduce back pain.
• Help the patient resume prebracing functional skills.
• Maintain muscle strength, particularly in the abdominals.
• Maintain or improve correct length and strength relationships of the spinal and extremity musculature. The general rule is to strengthen the muscles on the convex side and to stretch the muscles on the concave side. Asymmetric exercise is used to promote symmetry. For example, in a patient with a right thoracic, left lumbar curve, typical findings may include weakness of the right iliopsoas and right external oblique. Exercises that could be prescribed for this patient would include resisted right hip flexion at the end range with the patient sitting to address the weakness of the right iliopsoas. Weakness of the right external oblique can be addressed using a left upper extremity diagonal reaching movement pattern emphasizing right thoracic side bending (Fig. 30-1). Other functional exercises for scoliosis include the following:
  • The patient is positioned in prone and is asked to place both hands above his or her head while deviating the thorax away from the concave side of the curve (Fig. 30-2).
  • The patient is positioned in supine and is asked to reach overhead and extend the arm on the concave side (Fig. 30-3).
  • The patient is positioned in heel-sitting and is asked to place both hands forward and flat while emphasizing trunk axial elongation (Fig. 30-4). The patient is then asked to stretch both arms laterally away from the concave side of the curve.
  • The patient is positioned in side lying (convex side down) over the end of the table with a hand to provide balance (Fig. 30-5). A pillow can be placed directly under the apex of the thoracic convex curve. Once in this position, the patient is asked to reach overhead and then down toward the floor using the arm that is closest to the ceiling to enhance the stretch.
  • Swiss ball exercises can also be used, focusing on gaining increased thoracic side bending, while stretching the convex side (Fig. 30-6).
• Any of the strengthening exercises described in the intervention strategy section of Chapter 27 can be used to increase strength in the extensor muscle groups. Side-lying techniques (lying on the concave side) can be incorporated to strengthen the lateral muscle groups. The side-lying sit-up exercise is particularly effective (Fig. 30-7).

If surgery is considered, the primary goal of scoliosis surgery is to achieve a solid bony fusion. Even in the setting of adequate correction and solid fusion, up to 38% of patients still have occasional back pain. The postsurgical management includes the previously mentioned strategies and the following:26

• Breathing exercises to promote rib cage expansion, pulmonary hygiene, and effective coughing.
• Patient and family education.

Legg–Calvé–Perthes Disease

Legg–Calvé–Perthes disease, a disorder of the hip in young children, was described around the turn of the century, independently by Legg, Calvé, Perthes, and Waldenström.27 The incidence of Perthes disease varies considerably from place to place. Low rates of around 5 or 6 per 100,000 have been reported from British Columbia, Massachusetts, and rural Wessex, England, whereas rates of between 11 and 15.6 per 100,000 have been found in Liverpool, England.

There is considerable epidemiologic, histologic, and radiographic evidence to support the theory that Legg–Calvé–Perthes disease is probably a localized manifestation of a generalized disorder of epiphyseal cartilage manifested in the proximal femur because of its unusual and precarious blood supply.28,29

The definitive cause of Legg–Calvé–Perthes disease remains unknown. Many etiologic theories have been proposed. Most current etiologic theories involve vascular embarrassment, with repeated episodes of infarction and ensuing abnormalities.30

Clinical Findings

The onset is usually insidious, and the course is prolonged over a period of several years. The initial sign is a limp. The child may be small for his/her age. There may also be a slight dragging of the leg and slight atrophy of the thigh muscles. A positive Trendelenburg sign is often seen. There may be some out-toeing of the involved extremity. The patient complains of a vague ache in the groin that radiates to the medial thigh and inner aspect of the knee. Muscle spasm is another common complaint in the early stages of the disease. On examination, there is usually decreased abduction and internal rotation. The ROM examination may show contracture in hip flexion and adduction.

Intervention

The intervention for Legg–Calvé–Perthes disease remains controversial.31 The goal of treatment is to relieve pain and to maintain the spherical shape of the femoral head and to prevent extrusion of the enlarged femoral head from the joint. Children who are less than 6 years of age (possibly 5 years in girls) and those with minimal capital femoral epiphysis involvement and normal ROM are often followed with intermittent physical examinations and radiographs approximately every 2 months. In the more severe cases, there is lack of agreement regarding whether operative or nonoperative intervention is beneficial.27 In reviewing long-term studies, it is apparent that the results improve with time.32,33 Most patients (70–90%) are active and pain-free regardless of intervention. The prognosis is much improved if there is no collapse of the femoral head. An important aspect in the intervention is the containment of the femoral head in the acetabulum. This is ensured by maintaining the hip in abduction and mild internal rotation for an extended period, using the Atlanta Scottish-Rite Hospital Orthosis. Although this brace does not use internal rotation-like casts as some other orthosis do, it does maintain the hip in abduction and permits approximately 90 degrees of hip flexion. This allows the patient to run and ride a bicycle while wearing the brace.34 It is worth noting that forced abduction treatment can lead to damage of the lateral physis.35,36 The advantages of operative intervention for containment of the femoral head are short time of restriction of movement, a more permanent containment, and perhaps enhanced remodeling of the femoral head.

Physical therapy may be provided at home, school, or in the clinic. Treatment methods include

• observation only;
• ROM exercises in all planes of hip motion (especially internal rotation and abduction);
• bracing;
• casting.

Specific procedural interventions can be used to relieve the forces incurred during weight bearing (crutch training, aquatic therapy). Gait training may be initiated with an orthosis or with bracing. The specific gait pattern and assistive devices depend on the type of orthosis. Patient and family education is necessary to teach hip protection strategies, thereby minimizing degenerative changes as the child ages.

Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is the most common disorder of the hip in adolescents. The average age for girls in whom slipped capital femoral epiphyses develop is 12.1 ± 1 years and for boys 14.4 ± 1.3 years (Table 30-3).37 The term SCFE is actually a misnomer—it is characterized by a sudden or gradual anterior displacement of the femoral neck from the capital femoral epiphysis, while the head remains in the acetabulum.27 The effects of coxa vara and valga demonstrate the principles underlying the mechanism of this condition. While the adult femur has a collum angle of approximately 125 degrees, the developing femur demonstrates considerably more coxa valga initially.38 Failure of the epiphyseal plate occurs as a result of shear forces, which are forces applied parallel to the surface of the growth plate.39,40 The natural history of SCFE is that the capital femoral epiphysis eventually will fuse with the femoral neck at the end of adolescence. Two devastating complications that can affect the result adversely are avascular necrosis (osteonecrosis) and chondrolysis. These complications are uncommon sequelae in the untreated slip but are serious complications in the operative and nonoperative management of SCFE.41

Clinical Findings

The initiating traumatic episode may be as minimal as turning over in bed. Patients with chronic SCFE generally have a history of groin or medial thigh pain for months to years.27 Approximately 45% will have knee or lower thigh pain as their initial symptom.42 If the patient can walk, it is with difficulty and with a limp, often with external rotation of the involved foot. The pain is reported as dull or aching, and there can also be a mild weakness of the leg. The hip will often show decreased ROM, particularly of internal rotation, abduction, and flexion. On passive flexion of the hip, the patient will frequently externally rotate the leg. On the basis of the patient's history, physical examination, and radiographs, SCFE can be classified as a stable or unstable hip.41,43 In the stable hip, weight bearing is possible with or without crutches. In the unstable hip, the patient presents more with fracture-like symptoms, with pain so severe that weight bearing is impossible.1

Intervention

The goals of intervention are relief of symptoms, containment of the femoral head, and restoration of ROM.44 The current method of choice is in situ surgical fixation. The goal of containment is to maintain the sphericity of the femoral head. Other treatments are epiphysiodesis, osteotomy, salvage procedure, or spica cast. Complications from surgery include chondrolysis and/or necrosis of the femoral head, which increases the likelihood of significant joint degeneration in later years. Conservative intervention includes the use of traction for the relief of symptoms, at home or in the hospital, for periods ranging from 1 or 2 days to several weeks. Gait training postsurgery is initiated as soon as lower extremity strength and ROM are adequate for ambulation skills. The weight-bearing status can vary but is usually nonweight bearing or touch down weight bearing. Full weight-bearing is permitted when the growth plate has fused (within approximately 3–4 months).44

ROM exercises for the hip should be performed in all planes, but with particular emphasis on hip flexion, internal rotation, and abduction. Strengthening of the affected extremity is introduced when sufficient healing has occurred.

Scheuermann Disease

Scheuermann disease occurs in approximately 10% of the population, typically in pubescent athletes, and in males and females equally.45 The disease, considered to be a form of juvenile osteochondrosis of the spine, involves a defect to the ring apophysis where the vertebrae grow unevenly with respect to the sagittal plane resulting in an anterior angle that is often greater than the posterior angle.46 These structural changes can cause the vertebral end plate to crack, thus making it possible for disk material to bulge into the vertebral body (Schmorl node). The seventh and tenth thoracic vertebrae are most commonly affected.

Clinical Findings

The initial onset is typically asymptomatic but then progresses to lower and mid-level back pain, which can be severe and disabling. As the condition progresses, the patient may complain of an aching sensation in the upper spine. The patient may report pain at the apex of the curve, which can be aggravated by physical activity and by long periods of standing or sitting. In addition there may be observational evidence of an increased thoracic kyphosis and pain with thoracic extension and rotation, usually detected during a school physical or noted by the parents. Many patients often develop an excessive lordotic curve in the lumbar spine to compensate for the kyphotic curve above.

Intervention

The intervention depends on the severity but typically involves postural education, a modification of the aggravating activity, exercise, or bracing. The Schroth Method, which originated in Germany as a treatment for scoliosis, is an exercise system which uses isometric and other exercises to strengthen or lengthen asymmetrical muscles in the spine with the goal to halt or reverse progression of abnormal spinal deviations. The exercise program includes the stretching of the pectoralis major and minor muscles, and muscle strengthening exercises for the thoracic spine extensors (seated rotation and extension in lying exercises), and the scapular adductors.47

Spondylosis

Spondylolysis refers to a defect in the pars interarticularis, a stress fracture caused by repetitive extension and torsion of the spine. Spondylolysis is common in patients involved with sports where repetitive extension and rotation of the lumbar spine occur frequently.48 Bilateral spondylolysis at the same vertebral level can result in spondylolisthesis (see Chap. 28).

Clinical Findings

The patient typically presents with insidious onset of extension-related low back pain (LBP). Frequently, there is an associated reduction in hamstring flexibility. Occasionally, radiating pain, numbness, or weakness may be present. Physical examination may reveal hyperlordosis, ipsilateral paraspinal muscle spasm, and adaptive shortening of the hamstrings.49 The ROM examination reveals pain with spinal extension. The single-legged hyperextension test may localize the spondylolysis when standing on the ipsilateral leg (Fig. 30-8), although one study found this to be an insensitive test.50 Radiographically, the anteroposterior view may identify anatomic variants or developmental effects, whereas the lateral view may demonstrate spondylolisthesis or a lytic lesion, and oblique views may demonstrate a stress reaction of the pars interarticularis, the pathognomic neck of the Scottie dog lesion.49

Intervention

The conservative intervention includes activity modification with avoidance of any activities that cause pain. The exercise program focuses on strengthening of the abdominal muscles, and hip flexor and hamstring stretches, while avoiding lumbar extension. Once the athlete becomes pain-free, activity can be gradually increased. Bracing is somewhat controversial. Indeed, one study illustrated that the best results were obtained with a period of rest from sport for 3 months, regardless of whether bracing was used.51

Osteochondritis Dissecans

Osteochondritis dissecans (OCD) is a rare cause of anterior knee or elbow pain in the young athlete. OCD is a joint disorder in which fissures form in the articular cartilage and the underlying subchondral bone due to vascular deprivation (osteonecrosis). The result is fragmentation (dissection) of both cartilage and bone, and the free movement of these osteochondral fragments within the joint space, causing pain and further damage. If OCD occurs in the knee, it involves the weight-bearing portions of the medial and lateral femoral condyles.

Clinical Findings

Occasionally, pain may not be the most prominent symptom, but a catching sensation with joint motion may be the primary complaint if there is a loose body within the joint space. If the lesion is small, a painful arc is present during active and passive movement.

Intervention

When possible, nonoperative forms of management such as protected weight bearing (partial or nonweight bearing) and immobilization are used. However, nonsurgical treatment is rarely an option as the capacity for articular cartilage to heal is limited. As a result, even moderate cases require some form of surgery. Surgical treatment varies widely and includes arthroscopic drilling of intact lesions, securing of cartilage flap lesions with pins or screws, drilling and replacement of cartilage plugs, stem cell transplantation, and joint replacement.

Postoperative rehabilitation usually involves immobilization then physical therapy. During the immobilization period, isometric exercises are commonly used to restore muscle lost to atrophy without disturbing the cartilage of the affected joint. Once the immobilization period has ended, physical therapy involves protection of the joint's cartilage surface and underlying subchondral bone with maintenance of muscle strength and ROM and low-impact activities, such as walking or swimming.

Osgood Schlatter Disease

The apophysis of growing bones differs from the epiphysis of skeletally immature bone in that the apophysis is an independent center of ossification that does not contribute to the longitudinal length of a long bone. The apophysis does, however, contribute to the structure and form of mature long bone by serving as a site of tendinous or ligamentous attachment. Development of the tibial apophysis begins as a cartilaginous outgrowth, with secondary ossification centers appearing with subsequent progression to an epiphyseal phase when the proximal tibial physis closes and the tibial apophysis fuses to the tibia.3 OS disease is a benign traction apophysitis that occurs in the tibial tubercle. It is a self-limiting knee condition that is one of the most common causes of knee pain in active and nonactive adolescents.52 The condition occurs in active boys and girls aged 11–18 coinciding with periods of growth spurts. OS occurs more frequently in boys than in girls, with reports of a male-to-female ratio ranging from 3:1 to as high as 7:1. During periods of rapid growth, stress from repetitive contractions of the quadriceps is transmitted through the patellar tendon onto a small portion of the partially developed tibial tuberosity. This may result in multiple subacute avulsion fractures and inflammation of the tendon, and subsequent secondary heterotopic bone formation occurring in the tendon near its insertion.

Clinical Findings

The diagnosis of OS disease is relatively straightforward. There may or may not be a history of injury. Symptoms are typically unilateral, although 20–30% of cases can be bilateral in nature.3 In the acute phase the pain is severe and continuous in nature. The pain occurs during activities such as running, jumping, squatting, and especially during kneeling, acute knee impact, and ascending or descending stairs. There is often a visible lump over the site. The pain can be reproduced by extending the knee against resistance or stressing the quadriceps.

Intervention

The intervention for OS disease is usually symptomatic, including anti-inflammatory measures, rest from the offending activity, and judicious stretching of the quadriceps and hamstrings (adaptively shortened hamstrings require increased quadriceps force to overcome the tight posterior structures).3 Bracing or enforced joint immobilization is rarely required, although the more persistent cases may require cast immobilization for 6–8 weeks. The progressive quadriceps stretching exercises begin with a bolster placed under the hips of the prone patient to place the muscle on slack at the hip joint. As tolerated, the bolster is removed to place the hip in extension for a complete stretch of the extensor mechanism as indicated. Rarely, individuals will require surgical excision of symptomatic ossicles or degenerated tendons if symptoms persistent into skeletal maturity.

Sever Disease (Calcaneal Apophysitis)

The calcaneal apophysis serves as the attachment for the Achilles tendon superiorly and for the plantar fascia and the short muscles of the sole of the foot inferiorly.53 Sever disease is a traction apophysitis of the growth center of the calcaneus that occurs at the insertion of the Achilles tendon and which is a common cause of heel pain in the athletically active child, with 61% of cases occurring bilaterally.54 Sever disease typically affects children 8–13 years, with the peak incidence occurring at 11 years in young females and in 12 years in young males.55–57 Young gymnasts, soccer players, and dancers are particularly susceptible to this condition because of their repetitive jumping or landing from a height.58

Clinical Findings

Sever disease is characterized by pain, point tenderness, and local inflammation at the posterior calcaneus near the insertion of the Achilles tendon. Patients with adaptively shortened calf muscles, internal tibial torsion, forefoot varus, a dorsally mobile first ray, weak dorsiflexors, and genu varus may be more susceptible to Sever disease.3

Intervention

The intervention for Sever disease initially begins with a shortening of the gastrocnemius-soleus group using heel cups or heel wedges, and avoiding barefoot walking until becoming asymptomatic.59 Stretching of the gastrocnemius-soleus, with the knee extended and the knee flexed, is only initiated after symptoms have subsided. When stretching in the weight-bearing position any rear foot to lower leg or forefoot to rear foot abnormality should be corrected before and during the exercise. Dorsiflexion strengthening exercises along with foot intrinsic strengthening may also help manage symptoms.3

Little Leaguer Elbow

Repetitive throwing results in muscular and bony hypertrophic changes about the elbow. Little Leaguer elbow is a common term, credited to Brogden and Cros,60 for an avulsion lesion to the medial apophysis as a result of repetitive valgus stress. The term has since been used to describe a variety of pathoanatomic lesions in the immature athlete, all of which relate to the mechanics of throwing. Additional factors that influence its development include age, skeletal maturity, individual susceptibility, competitive level, and geographic location.61

The act of baseball pitching has been described in five stages62–65:

• Wind-up. This stage involves the initial preparation as the elbow is flexed and the forearm is slightly pronated, and is characterized by low load to the arm. Elbow flexion is maintained by an isometric contraction of the elbow flexors. During the stride of the wind-up phase, the biceps muscle contracts to isometrically and eccentrically control the elbow angle, while the wrist and finger extensors concentrically move the wrist from slight flexion to hyperextension.66,67
• Early cocking. This stage begins when the ball leaves the nondominant gloved hand and ends when the forward foot comes into contact with the ground. The shoulder begins to abduct and externally rotate, and valgus stress to the elbow begins.
• Late cocking. This stage is characterized by further shoulder abduction and maximal external rotation. At the elbow, flexion of between 90 and 120 degrees and increasing forearm pronation to approximately 90 degrees occurs. Dynamic stability is provided by the flexor–pronator muscle mass, and the triceps contracts isometrically to limit elbow flexion.67
• Acceleration. This phase is characterized by the generation of a significant anteriorly directed force on the upper extremity by the shoulder musculature, resulting in internal rotation and adduction of the humerus, accompanied by rapid elbow extension. The period from the late cocking stage through the acceleration phase is the time when the elbow is subjected to maximum valgus stresses.68
• Follow-through. This phase is characterized by the dissipation of all excess kinetic energy as the elbow reaches full extension and ends when all motion is complete. McLeod further divides this phase into release and deceleration.69

The repetitive motions involved in the various phases of throwing place colossal strains on the elbow, particularly during the late cocking and acceleration phases. These strains can result in inflammation, scar formation, loose bodies, ligament sprains or ruptures, and the more serious conditions of osteochondritis or an avulsion fracture.64,70 The onset of Little Leaguer elbow can be insidious or sudden, with the latter typically secondary to fracture at the site of the lesion.

Clinical Findings

The child typically presents with pain and local tenderness on the medial side of the elbow. Physical findings depend on the severity but commonly include persistent elbow discomfort or stiffness due to aggravation by the injury. A locking or “catching” sensation indicates a loose body. If the ulnar nerve is compromised, numbness in the ulnar distribution and a Tinel sign at the elbow may be present.

Intervention

Management is conservative, involving rest and elimination of the offending activity. Lesions involving less than 0.5–1 cm of apophyseal separation are initially treated with the rest. This is followed by a rehabilitation program similar to that described for medial epicondylitis except that resistance exercises are avoided until active range can be performed to full motion without pain (generally 2–3 weeks). Throwing is avoided for 6–12 weeks. If OCD is present, the joint needs protection for several months.71 Any separation greater than 0.5–1 cm, sudden traumatic avulsions, or a failure to respond to conservative measures are indications for surgery. The patient cannot return to pitching until full and normal motion and strength has returned.

To prevent elbow disorders, young athletes should adhere to the rules of Little League, which limits the number of pitches per game, per week, and per season and the number of days of rest between pitching.72 The pitch count is the most important of these statistics.

Proximal Humeral Epiphysitis

This condition, often referred to as Little Leaguer shoulder, is also known as osteochondritis, epiphysitis, and epiphysiolysis of the proximal humeral epiphysis.73 The proximal humerus ossifies from four ossification centers: humeral head, greater tuberosity, lesser tuberosity, and humeral shaft.74 The ossification center for the humeral head is usually radiographically evident within the first year of life, whereas the greater tuberosity appears at age 3 and the lesser tuberosity at age 5. The humeral head and tuberosity unite around age 6 to form a large proximal humeral epiphysis, which unites with the shaft around age 20.73 Injury to the proximal humeral epiphysis usually occurs because of the two mechanisms in throwers: distraction and torsion.

Clinical Findings

Patients typically describe pain localized to the proximal humerus during both throwing and resisted shoulder strength testing. Palpation demonstrates local tenderness over the proximal humerus. The differential diagnosis of shoulder pain in adolescents throwers include glenohumeral instability, rotator cuff tendinopathy, impingement, and proximal humerus physeal fracture.73 Radiographs characteristically show widening of the proximal humeral physis.

Intervention

Treatment includes cessation of throwing until the patient has pain-free ROM of the shoulder and radiographs return to normal, which may take up to 1 year.75

Pulled Elbow

The term pulled elbow or “nurse maid's elbow,” refers to a common minor soft-tissue injury of the radiohumeral joint in children of preschool age. The incidence of this condition is 3% in children under the age of 8,76 and it comprises 5.6% of all upper extremity injuries involving children under the age of 10.77,78 The left elbow is more commonly affected than the right,79and the disorder is more common in boys than in girls. The injury is caused by a sudden longitudinal traction force on the pronated wrist and extended elbow80,81 resuling in the radial head slipping through the annular ligament, which causes the fibers of the annular ligament to become interposed between the radius and the capitellum of the humerus.77,82

These are the more common causes of pulled elbow77:

• The child is lifted by an adult from the ground by his hands.
• The child's forearm, wrist, or hand is being held firmly by a parent as the child attempts to walk away.
• A mother grabs the hand of a child to prevent a fall as the child wanders toward something potentially harmful.
• The young child is lifted by the hand from a lying or sitting position.
• The child is swung around by the hands several times during the course of play.

Clinical Findings

There is usually no obvious swelling or deformity, but the child presents with a painful and dangling arm, which hangs limply with the elbow extended and the forearm pronated.77 The child is reluctant to use the arm and resists attempted supination of the forearm. The common sites of pain are (in order of occurrence) the forearm and wrist, the wrist alone, and the elbow alone.82

Intervention

The intervention of choice is manipulation.77 Before attempting the manipulation, it is important to explain the procedure to the parents and to win the confidence of the child, by gently supporting the injured arm before manipulation. During the procedure, the clinician holds the child's wrist with one hand while the other hand supports the elbow and palpates the radial head. The child's attention is diverted and the forearm is forcibly supinated with one quick motion, together with the application of downward pressure on the radial head. A click in the region of the radial head (palpable and sometimes audible) is indicative of a successful reduction. Sometimes, the forearm has to be pronated after forcible supination to reduce the pulled elbow. The click results from release of the trapped annular ligament. Soon after the manipulation, the child typically begins to use the arm again, but sometimes there can be a delay of a day or two. In such cases, a sling can be used to both give comfort and protect the arm from a recurrence.

The parents should be advised to avoid a longitudinal traction strain on the child's arm by not pulling on the hands or wrists.77

Distal Radial Epiphysitis

Radial physes appear at 12–18 months and fuse by 15–18 years.83 Distal radial apophyseal injuries are most common in male and female gymnasts but occasionally happen in other sports.

Clinical Findings

The patient typically describes a gradual onset of wrist pain made worse by weight-bearing activities while the wrist is in extension. Physical examination often reveals normal ROM but swelling of the distal radius. Tenderness is frequently found over the posterior (dorsal)-radial growth plate but may also be elicited on the anterior (volar)-radial physis as well. Radiographic findings depend on the stage of the disease. Although these injuries are usually confined to the distal forearm, the carpus can sometimes be involved.

Intervention

Time to healing is dependent on the stage of the disease in the radiographic findings. When radiographs are negative, 4 weeks of rest usually allow for healing and return to activities. In other cases, immobilization in a cast is the mainstay of treatment.

Arthrogryposis Multiplex Congenita

Arthrogryposis multiplex congenita (AMC) is a nonprogressive syndrome present at birth that is characterized by severe joint contractures, muscle weakness, and fibrosis.84 There are many known subgroups of AMC, with differing signs and symptoms. Some of the more common signs and symptoms are associated with the shoulder (internal rotation), elbow (extension and pronation), wrist (flexed and ulnarly deviated), hand (fingers in fixed flexion and thumb-in-palm), hip (flexed, abducted, and externally rotated, often dislocated), knee (flexion), and foot (clubfoot). Although the specific cause of AMC is unknown, several mechanisms have been suggested including hyperthermia of the fetus, prenatal virus, fetal vascular compromise, septum of the uterus, decreased amniotic fluid, and muscle and connective tissue developmental abnormalities.85

Clinical Findings

No definitive laboratory studies or invasive procedures are available to detect AMC. The clinical findings associated with AMC vary tremendously among infants and include those already mentioned. The purpose of the initial examination is to establish a baseline from which to set realistic goals. Measurements of passive, active, and functional ROM are assessed as are gross motor function and developmental milestones.

Intervention

The intervention for AMC involves a multidisciplinary approach. The cornerstone of the intervention is family education, including instruction on low load, prolonged stretching (3–5 sets of stretches per day, with 3–5 repetitions in each set, and each repetition held for 20–30 seconds), positioning, strengthening activities through play, facilitation of developmental activities, and teaching of compensatory strategies.86 Splints are adjusted for growth and improvement every 4–6 weeks. Reducing the disability associated with immobility is a major focus of treatment. Key functional motor skills such as rolling, hip hiking, and standing are addressed. Standing is initiated in standing frames with the lower extremities held in as optimally correct a position as possible with the help of splints and high-top shoes.86 In the preschool patients, goals should be to emphasize ability versus disability, improve the child's function in basic ADLs, and enhance independent immobility and ambulation with minimal bracing and assistive devices.86

Osteogenesis Imperfecta

Osteogenesis imperfecta (OI) is an inherited condition resulting from abnormality in the type I collagen (found in bones, organ capsules, fascia, cornea, sclera, tendons, meninges, and dermis), which causes the bones to be brittle. In the most severe forms, the infant is born with multiple fractures sustained in utero or during the birth process.

Clinical Findings

The diagnosis of OI is made primarily from clinical and radiographic findings, as no definitive laboratory test exists to identify OI. The clinical features of OI are extremely variable and depend on the type and severity of the disorder. Primary impairments include bone fragility, short stature, scoliosis, lax ligaments, weakened muscles, failure of postnatal growth, and multiple recurrent fractures sustained from minor or no trauma.86 The clinician should be aware of the infant's medical history of past and present fractures and know the types of immobilizations employed before beginning the examination.87–90 Pain is assessed using a tool such as the FLACC (face, legs, activity, cry, and consolability), which is an observational scale for assessing pain behaviors quantitatively with preverbal patients. Assessing active, but not passive, ROM is essential. Functional ROM may prove more useful because it will assist in visualizing the whole composite of motion needed in functional abilities. Assessing muscle strength is done through observation of the infant's movements and palpation of contracting muscles rather than by using formal manual muscle tests.

Intervention

Typical participation restrictions for an infant with OI depend on the severity of the case. Goals for infants with severe OI are to prevent deformities of the head, spine, and extremity; avert cardiopulmonary compromise by avoiding constant positioning in the supine position; and maximizing the child's ability to move actively.86,90 Caregiver education on proper and safe handling, positioning, and facilitation of movement is provided. Bathing, dressing, and carrying the infant are critical times when the infant is at risk for fractures.

The caregiver and clinician must be aware of the signs of a fracture which include inflammation (warmth of the site, edema, and pain), bruising, irritability, and deformity. An aquatic exercise program is an excellent therapeutic program for the child with OI. The degree of ambulation attainable varies for preschool children with OI. Gait training, which progresses in the usual fashion (parallel bars and moving to various assistive devices), is commonly initiated when the child has achieved strength with a rating of at least 3/5 (Fair) and when ROM has reached a plateau. In moderate to severe OI, braces and splints are usually required to begin standing activities on solid surfaces. It must be remembered that when children use walkers or crutches a large percentage of the body weight is borne through the upper extremities, necessitating precautions against bowing deformities of the radius and ulna. A walker that supports the majority of body weight through the trunk and pelvis is often used to assist in weight bearing during initial overland ambulation. Customized mobility carts may be fabricated to encourage independent mobility when the child is immobilized, enabling the child to explore his or her environment, gain some independence, and maintain strength in the upper extremities. Children with severe types of OI often require wheelchairs for mobility. Because of the shortened extremities, these chairs are often specially ordered and may require adaptations.

For severe cases presenting with severe osteopenia and repeated fractures, cyclic administration of intravenous aminohydroxypropylidene (i.e., pamidronate) may reduce the incidence of fracture and increase bone mineral density. Surgical interventions include intramedullary rodding, surgery for basilar impression, and correction of scoliosis.

Developmental Dysplasia of the Hip

Up to 10% of infants in the United States are born with congenital dislocation of the hip.91 The acronym CDH is confusing and has been used synonymously with congenital dislocation or congenital disease of the hip. A dislocated hip is a physical sign, not a diagnosis, and the term congenital means present at birth.92

Thus, the acronym DDH is replacing CDH. The word developmental invokes the dimension of time, acknowledging that the dysplasia or dislocation may occur before or after birth, while dysplasia means an abnormality of development and encompasses a wide spectrum of hip problems.92

DDH includes hips that are unstable, malformed, subluxated, or dislocated. Instability is the inability of the hip to resist an externally applied force without developing a subluxation or dislocation.92 A subluxation is an incomplete dislocation with some residual contact between the femoral head and acetabulum, whereas a dislocation indicates complete displacement of the femoral head from the acetabulum.92

The etiology of DDH is felt to be multifactorial, including both mechanical and physiological factors. In utero, the hip is in a position of flexion and abduction that results in a tightened iliopsoas tendon and anterior–lateral orientation of the acetabulum.93 The tight iliopsoas may push the femoral head out posteriorly with hip extension during kicking. The labrum (cartilaginous rim of the acetabulum) becomes everted and flattened.

The acetabulum and femoral head develop rapidly in the neonatal period. When the acetabulum and femoral head are in the correct position, each reinforces the development of the other by this physical contact; however, if the hip is not concentrically reduced, it will develop in a dysplastic manner.94–96 If the hip reduces spontaneously within a few days, hip development usually proceeds normally. In contrast, if a subluxation or dislocation persists, the femoral head becomes flattened on the posteromedial surface, the acetabulum becomes shallow and dysplastic, and femoral anteversion gradually increases.94–96In addition, the muscles surrounding the hip may shorten and contract.

Prolonged dislocation makes it difficult to return the femoral head to the acetabulum and is associated with a higher incidence of OA and impaired hip function in adulthood.91

Clinical Findings

The value of the neonatal hip screening examination remains controversial.92 At present, tests including the ones outlined below are currently used to examine the infant. The examination requires patience and skill, and the newborn must be relaxed on a firm surface.

The examiner attempts to reduce the dislocation or subluxation using the Ortolani and Barlow maneuvers.92

With the newborn supine, the clinician places the tips of the long and index fingers over the greater trochanter, with the thumb along the medial thigh. The infant's leg is positioned in neutral rotation with 90 degrees of hip flexion and is gently abducted while lifting the leg anteriorly.92 With abduction one can feel a clunk, as the femoral head slides over the posterior rim of the acetabulum and into the socket. This is the clunk originally described by Ortolani,97 and is called the sign of entry, as the hip relocates with this maneuver. Maintaining the same position, the leg is then gently adducted, while gentle pressure is directed posteriorly on the knee, and a palpable clunk is noted as the femoral head slides over the posterior rim of the acetabulum and out of the socket.92 This clunk was originally described by Barlow,98 and is called the sign of exit, as the hip dislocates with this maneuver. Both tests are designed to detect motion between the femoral head and the acetabulum.92 The reproducibility of these tests is dependent on ligamentous or capsular laxity, which usually disappears by the age of 10–12 weeks.92

Clinical screening programs are important in reducing the incidence of surgery. Ultrasound is the diagnostic modality of choice.99 Early intervention has been reported to lead to a successful outcome in 90 and 96% of children radiographically and functionally, respectively.94–96 Later examinations include assessment of gluteal folds, knee height, and the degree of hip abduction.100 In the 3- to 12-month-old infant, the best physical finding is a limitation of hip abduction. In the supine position, with the hip in 90 degrees of flexion and one hand stabilizing the pelvis, each hip should easily abduct to 75 degrees and adduct to 30 degrees past the midline.92 In the older child, a limp, positive Trendelenburg, toe-walking, in-toeing, or out-toeing may be secondary to DDH.92

Intervention

The treatment of this condition depends on the age of the patient and the severity of the condition. The goal of intervention is to safely obtain and maintain a concentric reduction of the hip to provide an environment for normal bony development. The conservative approach is most effective for infants whose subluxation or dislocation have been discovered and treated early, within the first 6 months of life. The conservative approach involves maintaining the hip in flexion and abduction through diapering, and bracing/splintinguntil it is adequately remodeled.

• Diapering. The child is placed in 2 to 3 diapers, which is designed to hold the legs in abduction, and parents are instructed to position the infant in hip flexion as well.
• Pavlik harness. The preferred conservative intervention is an outpatient intervention regimen using the Pavlik harness, that provides effective reduction in 90% of the cases.100 However, the harness is ineffective after 3 weeks making early detection critical. In infants older than 9 months who are beginning to walk independently, an abduction orthosis can be used as an alternative to the Pavlik harness.31 The harness, which is initially worn 24 hours a day for 6–12 weeks, is used if symptoms persist after several weeks and is designed to restrict hip extension and adduction while allowing the hip to be maintained in flexion and abduction. 31 This “protective position” of flexion and abduction enhances normal acetabular development, and the kicking motion allowed in this position stretches the contracted hip adductors while promoting spontaneous reduction of the dislocated hip.31 After the initial period, the harness is worn 12 hours per day for 3–6 additional months or until both clinical and radiographic signs are normal,100. If the Pavlik harness is used, it is important to teach the parents that the hips are placed in the correct position—too much flexion or abduction can cause excessive pressure through the femoral heads, resulting in possible avascular necrosis.

In more severe cases, skin traction, closed reduction, and spica-cast application may be needed. Open reduction and recasting are also options. In rare cases, total hip replacement is necessary in later life.

Equinovarus

Clubfoot, or talipes equinovarus, is a deformity consisting of hindfoot equinus (i.e., plantar flexion), hindfoot varus (i.e., the long axis of the talus lies lateral to the base of the first metatarsal bone), and forefoot varus (i.e., the forefoot is curved inward in relation to the heel, the heel is bent inward in relation to the leg, and the ankle is fixed in plantar flexion with the toes pointing down), which can be classified as follows:

• Inversion at the subtalar joint
• Adduction at the talonavicular joint
• Equinus at the talocrural (ankle) joint (plantarflexed position)
  • Fixed or rigid: this type of equinovarus can be either correctable without surgery (i.e., flexible) or require surgical release (i.e., resistant).

Clinical Findings

The clinical findings vary according to severity. Most cases are detected with fetal screening using an ultrasound scan.

Intervention

Treatment consists of manipulation (reducing the talonavicular joint by moving the navicular laterally and the head of the talus medially), taping, stretching, and serial casting, which is most effective if started immediately after birth. Other options include knee ankle foot orthoses (KAFO), Dennis-Brown bars with straight last boots, ankle foot orthoses, and/or custom foot orthoses. The role of the clinician involves monitoring, providing developmental intervention to promote typical functional skills and to assist in stretching and splinting.

Congenital Limb Deficiencies

Congenital limb deficiencies can be described as transverse and longitudinal.

• Transverse: These types resemble amputation to a residual limb in which the limb has developed normally to a particular level, but beyond which no skeletal elements are present. These deficiencies are described by naming the segment at which the limb terminates and the level within the segment beyond which no skeletal elements exist. For example, a child's lower extremity has a fully developed femur, but no tibia, fibula, tarsal, metatarsals, or phalanges.
• Longitudinal: These include all of the cases that are not transverse and involve a reduction or absence of an element or elements within the long axis of the limb. These deficiencies are named according to the bones affected (in a proximal-distal sequence) and whether the affected bone is totally or partially absent. For example, a child who is missing the radius and thumb in one upper extremity, with the ulna, carpals, and other digits present.

In the upper limb, congenital deficiencies most frequently involve the hand. According to the Association of Children's Prosthetic and Orthotic Clinic (ACPOC), 60 percent of congenital limb deficiencies either have no known cause or are genetic in origin. Although some congenital abnormalities may be due to poor blood supply to the fetus due to constricting amniotic bands, only 4 percent are due to taking some type of drug or toxin (i.e., maternal drug exposure like thalidomide).

Clinical Findings

The clinical presentation varies according to the type of children with limb deficiencies, the level of the deficiency, and the number of deficiencies or limbs involved.

Intervention

The intervention is directed toward helping the child develop appropriate functional and developmental skills while reducing any secondary impairments, such as soft-tissue contractures. Some children with congenital limb deficiencies may be candidates for an Ilizarov procedure, an orthopaedic surgical procedure that involves gradual lengthening of the limb over many months using implanted pins connected to a traction device.

The field of geriatrics continues to gain attention due to the rapid growth of this segment of the population and its predicted future socioeconomic impact. It is therefore inevitable that future rehabilitation professionals will see an increase in the number of elderly individuals seeking services for the management of both acute and chronic conditions that can negatively impact active life expectancy or the number of years that an individual may expect to be independent in ADLs.101,102 Therefore, rehabilitation, with its potential to restore function, prolong independence, and improve quality of life, can be extremely important in this population.

The Aging Process

Aging is the accumulation of diverse adverse changes that increase the risk of death.103 The rate of aging, that is, the rate at which aging changes occur, typically varies from individual to individual, resulting in differences in the impact of aging on function.103 The aging process can be attributed to a combination of development, genetic defects, the environment, social and recreational habits, and disease, some or all of which are responsible for sequential alterations that accompany advancing age and the progressive probability of experiencing a chronic debilitating disease.103 This increase in the incidence of chronic conditions with advancing age occurs largely because this period in life is often accompanied by a deterioration in health and a subsequent loss of independence. Complicating matters is the presence of comorbidities at this time of life, such as cardiovascular disorders, osteoporosis, arthritis, and diabetes, which increase the vulnerability of the geriatric patient.

Musculoskeletal impairments are some of the most prevalent and symptomatic health problems of middle and old age,104 and result in a gradual loss of strength, motion, and increasing pain. These changes prevent elderly individuals from participating in regular physical activity, optimum mobility and, in some cases, reduce independence.105 The history and physical examination of the geriatric patient must differentiate between the effects of aging, inactivity, and disease on the underlying impairments and functional limitations that result in movement dysfunction.106 For example, mild impairments in the ROM may be due to increased stiffness associated with aging that occurs in the tendinous or ligamentous structures around a joint, or it could be due to acute immobilization, or chronic inactivity and reduced demands on a particular joint for full ROM.107

Theories of Aging

Normal aging produces age-related changes that are the result of the passage of time rather than the result of pathologic conditions. A wide array of theories exist as to why aging occurs, why species have the life spans they do, and what kinds of factors are likely to influence the aging process. For example, the aging process has been attributed to the following:

• Glycosylation.108–110 Glycosylation involves the abnormal process of the binding of glucose (simple sugar) to protein, a process that requires oxygen. Once this binding has occurred, the protein becomes impaired and is unable to perform as efficiently. Examples of known cross-linking disorders include senile cataract and the appearance of tough, leathery, and yellow skin.
• Neuroendocrine-immuno theory.111–114 The immune system is the most important line of defense against foreign substances that enter the body. With age the system's ability to produce necessary antibodies that fight disease declines, as does its ability to distinguish between antibodies and proteins. In a sense the immune system itself becomes self-destructive and reacts against itself.
• Damage by free-radical reactions.115 The term free radical describes any molecule that has a free electron. Theoretically, this free electron reacts with healthy molecules in a destructive way by creating an extra negative charge. This unbalanced energy makes the free radical bind itself to another balanced molecule as it tries to steal electrons. In so doing, the balanced molecule becomes unbalanced and transforms into a free radical itself. It is known that diet, lifestyle, drugs (e.g., tobacco and alcohol), radiation, and so on are all accelerators of free radical production within the body. However, there is also natural production of free radicals within the body as a byproduct of energy production, particularly from the mitochondria.
• Planned obsolescence.103 This theory focuses on the genetic programming encoded within the DNA, the blueprint of individual life obtained from parents. Individuals are born with a unique code and a predetermined tendency to certain types of physical and mental functioning that regulate the rate at which we age (graying of hair, wrinkles, etc.). Many genes show changes in expression with age and these premature aging syndromes provide evidence of defective genetic programming: Hutchinson–Gilford syndrome and Werner syndrome
• Telomere shortening. This theory was born from the surge of technological breakthroughs in genetics and genetic engineering. Telomeres are DNA–protein complexes that cap the ends of chromosomes and promote genetic stability. Each time a cell divides, a portion of telomeric DNA dwindles away, and after many rounds of cell division, so much telomeric DNA has diminished that the aged cell stops dividing. Thus, telomeres play a critical role in determining the number of times a cell divides, its health, and its life span.
• Caloric restriction. Calorie restriction or energy restriction is a theory proposed after years of animal experiments and research on longevity that demonstrated how a high-nutrient low-calorie diet can dramatically retard the functional, if not the chronological, aging process.
• Evolutionary theory. As evolution acts primarily to maximize reproductive fitness in an individual, longevity is a trait to be selected only if it is beneficial for fitness. Over successive generations, late acting deleterious mutations will accumulate in the population and ultimately lead to pathology and senescence.

As previously mentioned, coexisting pathologic processes or comorbidities can exacerbate the effects of other conditions and result in greater functional limitations and disability. Throughout youth and early adulthood, the body has a number of physiologic reserves from which to draw upon when faced with physical challenges and injury, without a loss of functional abilities. However, older individuals have fewer of these system redundancies due to a gradual decline of health and increased incidence of injury and disease.105 Without these physiologic reserves, an older individual is more susceptible to functional limitations and disability, resulting in frailty—the opposite end of the spectrum from successful aging.105

Pathological Conditions Associated with the Elderly

The geriatric patient who has been given a prescription for physical therapy may not have been physically active for some time, and his or her level of fitness may have declined considerably. Age-related changes of the heart and blood vessels, which can either be mitigated or exacerbated with activity level, typically result in reduced capacity for oxygen transport at rest and in response to situations imposing an increase in metabolic demand for oxygen.105 In addition, maximal oxygen consumption decreases 5–15% per decade after the age of 25 years.116 As a result, at submaximal exercise, cardiac output and stroke volume are lower in older adults at the same absolute work rates, while blood pressures tends to be higher.116 It is very important that elderly patients have a physician's evaluation of their cardiovascular status before engaging in a rehabilitation program. In addition, the patient should be carefully monitored for their cardiovascular response and tolerance to exercise during their rehabilitation sessions. Heart rate, blood pressure, and rate of perceived exertion (RPE) should be assessed before, during, and after exercise, and the physician should be notified of any abnormal or unusual findings. In addition to the normal aging changes a number of complications can occur in the elderly:107

• Acute inactivity, such as that which occurs with hospitalization, can significantly reduce VO2max and increase blood viscosity and venous status, which increases the risk of thromboembolic disease. Immobility is a common pathway by which a host of diseases and problems in the elderly produce further disability. Persons who are chronically ill, aged, or disabled are particularly susceptible to the adverse effects of prolonged bed rest, immobilization, and inactivity. Common causes for immobility in the elderly include arthritis, osteoporosis, fractures (especially hip and femur), podiatric problems, and neurologic disorders and diseases (see next)
• Neurologic disorders and diseases. A wide variety of neurologic disorders and diseases can affect the aging population, including cerebrovascular accident, Parkinson disease, cerebellar dysfunction, neuropathies, cognitive, psychological and sensory problems (depression, fear and anxiety), pain, and impaired vision. Age-related changes in the brain start at approximately age 60, although normal, nonprogressive, and negligible declines among the aged do not dramatically impact daily functioning until the early 80s. Many cognitive disorders require timely identification and intercession to offset permanent dysfunction.
• Dementia and Delirium. Primarily a disease of the elderly, dementia is a generic term used to describe a progressive, persistent loss of cognitive and intellectual functions. Dementia is associated with a history of chronic, steady decline in short- and long-term memory, depression, and with difficulties in social relationships, work, and activities of daily living. The typical end result of dementia is impairment of cognition including a decline in alertness, orientation, emotion, behavior, memory, perception, language, the application of knowledge (praxis), problem solving, and judgment. In contrast, delirium presents with an acute onset of impaired awareness, confusion, easy distraction, and disturbances of perception (e.g., misinterpretations, visual hallucinations).
• Cardiac diseases, such as coronary artery disease (CAD) and the sequelae of myocardial infarction (MI) and cardiomyopathy:
  • CAD is a complex disease of the cardiac arteries resulting in ischemia to the myocardium. The clinical symptoms of CAD include angina (an ache, pressure, pain, or other discomfort in the chest, arms, back, or neck), shortness of breath, a decrease in activity tolerance, or palpitations.
  • MI is a development of myocardial necrosis caused by an imbalance between the oxygen supply and demand of the myocardium, typically resulting from plaque rupture with thrombus formation in a coronary vessel, and subsequent acute reduction of blood supply to a portion of the myocardium. This patient population is a much greater risk of an adverse event during exercise, and therefore careful consideration, screening, and monitoring must occur to ensure safety with a rehabilitation program.
• Hypertension. Hypertension, which may be either essential or secondary, can have a number of negative impacts including the following:117–126
  • Left ventricular hypertrophy, left atrial enlargement, aortic root dilatation, arrhythmias, and ischemic heart disease.
  • Hemorrhagic and atheroembolic cerebrovascular accident (CVA) or encephalopathy.
  • Increased glomerular hydrostatic pressure secondary to efferent glomerular arteriolar constriction, which results in a reduction in renal blood flow in conjunction with elevated afferent glomerular arteriolar resistance.
• Musculoskeletal. The musculoskeletal changes associated with aging affect all of the soft tissues and bone. Many of these changes are associated with a decrease in physical activity. Muscle size can decrease an average of 30–40% over one's lifetime, affecting the lower extremities more than the upper extremities.127 Type II muscle fibers, which are used primarily in activities requiring more power are not stimulated by normal ADLs disappear at a faster rate than Type I fibers. Indeed, Type II fibers decrease from an average of 60% of total muscle fiber type in sedentary young men to below 30% after the age of 80.128 Therefore, the focus on this age group should be the prescription of exercises that develop power, not just strength. In addition, a loss of range in the lower extremities can have a negative impact on functional activities such as gait. Two musculoskeletal conditions that can severely impact function in the geriatric population are osteoporosis and osteoarthritis. Fractures, which can have a significant impact on morbidity, mortality, and functional dependence, commonly occur among the elderly. Such fractures include pathologic fractures, proximal femur fractures, proximal humerus fractures, distal radius fractures, compression fractures of the spine, and stress fractures. Fractures in the elderly have their own set of problems:
• The fractures heal more slowly.
• Secondary complications, including the following:
  • Pneumonia and/or decubiti (if the fracture results in a prolonged period of immobility or bedrest).
  • Detrimental changes in mental status secondary to adverse reactions to anesthesia or pain medications.
  • Decreased vision placing patients at increased risk of falls.
  • Poor balance exacerbated by limited weight-bearing status after a lower extremity fracture.
• Gait deviations. Individuals over 65 tend to walk with a slower self-selected gait speed, a shorter stride width, and an increase in double support time. Some of these changes are the inevitable effects of aging, while others are due to pathology or disuse. In addition, elderly patients tend to demonstrate increased gait variability. For example, elderly individuals tend to go through a decreased range of dorsiflexion during midstance.129,130 However, significant changes in gait are not noted unless multiple joints are involved or there are impairments in other systems such as loss of strength or motor control.

Bloem and colleagues131 in a study of individuals aged over 88 noted that 20% of the subjects exhibited unimpaired gait. Another study has demonstrated that those who exhibit senile gait disorders are more likely to go on to develop dementia and die earlier than age-matched individuals who walk normally.132 This raises the enticing possibility that gait changes associated with aging may actually be an early manifestation of pathologies such as subtle white matter changes, vestibular dysfunction, musculoskeletal disorders, or visual changes.132 What is known is that sensory system impairments have a tremendous impact on gait, and that training to improve proprioception can improve gait parameters and safety.133

• Impaired balance. Age-related balance dysfunctions can occur through a number of mechanisms including gradual degenerative changes in the vestibular apparatus of the inner ear, an inability to integrate sensory information, and muscle weakness. In addition, some diseases (benign paroxysmal positional vertigo), cerebrovascular disease, Ménière's disease, cerebellar dysfunction, vertebrobasilar artery insufficiency, and cardiac disease common in aging populations can lead to further deterioration in balance function. Balance disorders can also be associated with a number of other causes including
  • medications,
  • postural hypotension,
  • visual/auditory deficits.

It is important to remember that frailty is not a natural consequence of aging. Physical activity throughout the aging years can produce a number of physiologic benefits:

• Substantial improvements in cardiovascular functioning.
• A significant impact on the maintenance of independence in old age.
• The prevention and/or postponement of age-associated declines in flexibility, balance, and coordination.

In contrast, disuse exacerbates the aging process. Intervention strategies to prevent disability from immobility should include the following, while monitoring vital signs:

• Minimize duration of bed rest. Avoid strict bed rest unless absolutely necessary. The patient should be allowed to stand 30–60 seconds during transfers (bed to chair).
• Encourage sitting up at a table for meals, and getting dressed in street clothes each day.
• Encourage daily exercise as a basis of good care. Exercises should emphasize balance and proprioception, strength and endurance, coordination and equilibrium, aerobic capacity, and posture.
• Design possible ways to enhance mobility through the use of assistive devices (e.g., walking aids, wheelchairs) and making the home accessible. If the patient is bed-bound, proper body alignment should be maintained and the patient should change positions every few hours. Pressure padding and heel protectors may be used to provide comfort and prevent pressure sores.
• Encourage socialization with family, friends, or caregivers.
• Regular checks of skin integrity, protective and discriminatory sensations

Falls

Falls in the elderly are often associated with significant morbidity and can be markers of poor health and declining function.134 Elderly patients with known risk factors for falling should be questioned about falls on a periodic basis. Recurrent falls, defined as more than two falls in a 6-month period, should be assessed for treatable causes. It is particularly important to assess housing arrangements, environmental hazards, alcohol use, and compliance with medications.

Several functional balance measures have exhibited a strong correlation with a history of falling. These simple tests, which can also be used to measure changes in mobility after interventions have been applied, are quantifiable and correlate well with the ability of older adults to ambulate safely in their environment.

• Timed single-leg stance (SLS). The patient stands unassisted on one leg (by flexing the opposite knee to allow the foot to clear the floor) for 30 seconds. The choice of which leg to stand on can be determined by the patient based on personal comfort. The clinician times the patient's one-leg balance using a watch. The ability to maintain SLS generally decreases with increasing age. One study135 found that older adults in the community could maintain the SLS for 10 sec about 89% of the time and nursing home residents for 45% of the time.
• The timed “Up & Go” test. The timed “Up & Go” test measures, in seconds, the time taken by an individual to stand up from a standard arm chair (seat height of approximately 46 cm/18.4 in, arm height 65 cm/25.6 in), walk a distance of 3 m (10 feet), turn, walk back to the chair, and sit down again. The patient wears his/her regular footwear and uses his/her customary walking aid (none, cane, or walker). The subject walks through the test once before being timed in order to become familiar with the test. Either a wrist-watch with a second hand or a stop-watch can be used to time the performance.

Overall physical function should also be assessed. This is accomplished by evaluating the patient's ADLs and instrumental ADLs.

Physical Therapy Intervention

The intervention is directed at determining the underlying cause of the fall, the identification of risks, and in preventing recurrence through patient and family/caregiver education on safety issues (adequate lighting, contrasting colors, and reduction of clutter). Functional training should include sit to stand transfers, walking and turning, and stair negotiation. Therapeutic exercises should be designed to address any strength and flexibility deficits, and balance and/or gait deficits.

Both male and female children are basically equal in physical condition and have the same strength before puberty. After puberty (Table 30-2), females aged 11–12 years are 90% as strong as their male counterparts versus 85% as strong at ages 13–14, and 75% at ages 15–16 years.136

Although skeletal muscle physiology in men and women does not differ significantly—the actual number of muscle fibers is similar between genders—men do appear to demonstrate larger absolute strength gains due to a larger cross-sectional muscle fiber size. When comparing strength to lean body mass or cross-sectional area, women are about equal to men and are equally capable of developing strength relative to total muscle mass. However, differences in anatomy make the female more prone to certain injuries. For example, women demonstrate greater amounts of static external knee rotation, greater active internal hip rotation, and increased hip width when normalized to femoral length than men, resulting in a number of structural combinations:137

• Women have an increased hip adduction, femoral anteversion, and genu valgum resulting in a larger Q angle and rotational positioning of the lower extremity (see Chap. 20).
• Women have anatomical differences at the knee that predispose them to a higher incidence of anterior cruciate ligament (ACL) injury (see Chap. 20).

Despite these differences, both men and women should undergo similar strength training progressions.

Female-Related Conditions

Pregnancy

Pregnancy is a state of wellness that spans approximately 40 weeks from conception to delivery. A number of physiologic changes occur during pregnancy and the postpartum period within the various body systems that can present the clinician with some unique challenges. Given the number of physiologic changes during pregnancy and the postpartum period within the various body systems, the extent of the physical therapy intervention will depend on the findings of the examination.

Endocrine System

Changes that occur in the endocrine system include but are not limited to the following:

• Enlargement of the adrenal, thyroid, parathyroid, and pituitary glands.
• An increase in hormonal levels to support the pregnancy and the placenta and in preparation for labor. For example, a female hormone (relaxin) is released that assists in the softening of the pubic symphysis so that during delivery, the female pelvis can expand sufficiently to allow birth. Unfortunately, the hormone is not specific to this region and produces greater laxity in all joints.138,139 This can result in an increased susceptibility to musculoskeletal injury.

Musculoskeletal System

The recommended weight gain during pregnancy is 25 to 27 pounds.140 Pregnancy can produce a number of changes within the musculoskeletal system:

• The abdominal muscles are stretched and weakened.
• The development of relative ligamentous laxity, both capsular and extracapsular.
• The rib cage circumference increases resulting in a natural state of hyperventilation to meet the oxygen demands.
• Pelvic floor muscle weakness due to the increased weight and pressure directly over these muscles—the pelvic floor drops as much as 2.5 cm (1 inch) as a result of pregnancy.141 Pelvic floor muscle weakness can result in stress incontinence (refer to “Urinary Incontinence”).
• Postural compensations to maintain stability and balance. These changes are related to the weight of growing breasts, and the uterus and fetus, resulting in a shift in the woman's center of gravity in an anterior and superior direction. Specific postural changes include an increased lumbar lordosis, an increased thoracic kyphosis with scapular retraction, and an increased cervical lordosis and forward head. These changes in posture can become habitual postpartum.
• Changes in gait. In advanced pregnancy, the patient develops a wider base of support and increased external rotation at the hips and demonstrates increased difficulty with walking, stair climbing, and rapid changes in position. 142

Common diagnoses associated with some of the above include

• Symphysis pubis dysfunction (SPD).143–146 This disorder can occur as a result of trauma during vaginal delivery. SPD should always be considered when treating patients in the postpartum period who are experiencing suprapubic, sacroiliac, or thigh pain. Subjectively the patient reports pain with any activity that involves lifting one leg at a time or parting the legs (e.g., lifting the leg to put on clothes, getting out of a car, turning over in bed, and walking up stairs). Objectively, the patient typically demonstrates an antalgic, waddling gait. Palpation reveals tenderness over the anterior pubic symphyseal area, and occasionally, clicking can be felt or heard. The ROM examination reveals limited hip movements due to pain, and there is an inability to perform unilateral standing. Radiological evaluation may occasionally be useful in confirming the diagnosis, although the amount of symphyseal separation does not always correlate with severity of symptoms or the degree of disability.147

Although the symptoms can be dramatically severe, a conservative management approach, including bed rest in the lateral decubitus position, pelvic support with a brace or girdle, ambulation with an assistive device and a graded exercise progression.147 Patient education, which is extremely important in terms of providing advice on how to avoid stress to the area, should include the following suggestions:

• Use a pillow between the legs when sleeping, and keep the legs and hips parallel and as symmetrical as possible when moving or turning in bed and when standing and turning. Silk/satin sheets and night garments may make it easier to turn over in bed.
• Move slowly and without sudden movements.
• Sit down to get dressed, especially when putting on socks, shoes, or pants.
• If bending over to pick up objects is difficult, use specific devices such as reachers.

Swimming, with the exception the breaststroke, and deep-water aerobics using floatation devices may help relieve pressure on the joint.

The symptoms of SPD typically resolve in approximately 6–8 weeks with no lasting sequela, although in rare cases residual pain occurs, requiring several months of physical therapy.147 In severe cases surgical intervention may be utilized in cases of inadequate reduction, recurrent diastasis, or persistent symptoms.

• Low back pain.142,148–155 LBP during the childbearing year is quite prevalent with the incidence ranging from 47 to 82%.156,166,167 Back pain after delivery has been reported to occur 67%, while 37% experienced back pain 18 months postpartum.151 Back pain tends to begin early in pregnancy, with 25% prevalence at 12 weeks.149 The most common location of back pain in pregnant women is the sacroiliac region. The cause of back pain during the childbearing year is thought to be related to the mechanical and hormonal changes. Several studies indicate that women with severe LBP during pregnancy are at extremely high risk for developing new episodes of severe LBP during a subsequent pregnancy as well as later in life.168–170 It is not clear whether the LBP is the result of the shift in the center of gravity, the associated postural changes, or changes to an intervertebral disk due to the release of relaxin. However, disk herniations are no more common during pregnancy than at other times. It is also important to consider systemic causes for LBP in this population. Kidney or urinary tract infections can both cause LBP.
• Peripartum posterior pelvic pain (PPPP). PPPP can be defined as unexplained and undiagnosed pain in the pelvic region (with or without radiation) that started during pregnancy or within 3 weeks after delivery. About 49% percent of pregnant women experiences some type of pelvic pain,171 with 33% of these women experiencing severe pain.152,157,158 The pain is typically experienced in the lumbar region and over the sacroiliac joints (with no findings suggesting nerve root involvement). Although the etiology of PPPP is unknown, it has been linked to the many physiological adaptations that occur in preparation for childbirth. The previously mentioned change in the center of gravity leads to a change in the degree of lordosis of the spine, which in turn affects the paraspinal musculature. In addition, the hormonal changes that occur during pregnancy may cause an imbalance between the ligaments, muscles, and joints in the posterior aspect of the pelvis.159 Although a systematic review160 of the literature investigating the effectiveness of physical therapy interventions in the treatment of PPPP and LBP found scant evidence to support the use of exercise or mobilization in this patient population, exercise is thought to be beneficial in the post-partum period. In addition, the patient should be given posture/body mechanics advice using the suggestions listed for SPD.

Coccydynia.161–165

Pain in and around the region of the coccyx, especially with sitting, is relatively common postpartum. Seating adaptations such as a donut cushion can be prescribed to lessen the weight on the coccyx and to support the lumbar lordosis. If symptoms persist for more than a few weeks, the displaced coccyx can often be corrected manually (see Chap. 29).

• Diastasis recti abdominis (DRA). A DRA is known as a split between the two rectus abdominis (RA) muscles to the extent that the linea alba may split under strain. The size of the DRA can vary from 2–3 to 12–20 cm in width and from 12–15 cm to the entire length of the recti muscles. It has not been determined whether the separation is a true tear or a relaxation of the tissue. A DRA is common in pre- and postpartum women. Predisposing factors for a DRA in women include obesity, a narrow pelvis, multipara, multiple births, excess uterine fluid, large babies, and weak abdominals prior to pregnancy. The separation may develop during the second and third trimesters of pregnancy, during second stage labor, and during the postpartum period. It is believed that a DRA may hinder the abdominal wall function related to posture, trunk stability and strength, respiration, visceral support, diminished pelvic floor facilitation, and delivery of the fetus. An umbilical hernia may result as well. The DRA is believed to contribute to chronic pelvic and LBP.
  • Criteria have been established for determining a DRA. The patient is positioned in the hook lying position. The clinician palpates with fingers horizontally, at the umbilicus and 2 inches above and below the umbilicus, and the patient is asked to raise their head and shoulders while reaching toward their feet. Any separation will be palpable, and a wide ridge of bulging tissue may actually be visible. If a DRA of 1–2 fingers width (1–2 cm) is present, this is considered within normal limits.174 Any separation greater than two-finger wide constitutes a DRA, and, therefore, restrictions on abdominal exercise prescription should apply. However, it is worth remembering that the interrater reliability for measuring a DRA by manually inserting the fingers into the gap has been considered poor.
  • Electromyography studies of the rectus abdominis (RA) and external oblique have been done on primiparas women during the pre- and postpartum stages.172 It was found that the abdominals generated the same muscle activity throughout the pregnancy; however, the ability to stabilize the pelvis against resistance decreased as the pregnancy progressed and continued to remain low postpartum.172 It was observed that the RA length, angles of insertion, and DRA were significant between 18 and 30 weeks, with further structural changes between 26 and 38 weeks; therefore, the ability to produce torque may be reduced.172 The decreased functional deficits were present up to 8 weeks postpartum, in conjunction with the incomplete resolution of the structural adaptations of RA. It is essential that these functional and structural deficits be addressed with pre- and postpartum women.172
  • Ostgaard et al.167 found that individualized exercise and education were significantly helpful in reducing back pain during the 8-week postpartum phase; however, no differences in back pain were found during pregnancy. Weekly physical exercise before pregnancy was found to reduce the risk for back pain during pregnancy. Diagnostic ultrasound has been used to determine exercise effectiveness on decreasing the amount of a DRA.173 It was determined that when performing a curl-up, the RA contraction significantly reduced the DRA compared to other movements studied.173 The additional movements tested were curl-up with rotation to left and right, posterior pelvic tilt, and abdominal hollowing.173 There was no evaluation of a possible relationship between DRA and back pain.
  • A RA that had exercised prior to the onset of pregnancy was not present in those women. Although it was not a controlled variable in this study, exercise prior to pregnancy may reduce the risk of a DRA.
  • According to Noble,166 exercises for the abdominals to prevent, decrease, and/or eliminate a DRA should be prescribed. Proper exercise intensity is essential, and intervention should occur as soon as possible. If exercise has not been started before or during pregnancy, basic abdominal isometrics with exhalation should begin within 24 hours of delivery.174 On postpartum day 3, the abdominals should be evaluated for a DRA.174 Curl-ups with the abdominal isometric and the crossover of the upper extremities for additional support can be done.166 If the DRA is greater than three fingers width (3 cm), there are restrictions on curl-ups and leg lowering exercises.174 Curl-ups of the head only, with the abdominal isometric and the crossover of the upper extremities, should be prescribed.174 Advancement of the exercises should not occur until the DRA has decreased.174 Many times women will actually increase the DRA during the postpartum phase with abdominal exercises that are too aggressive for the individual.174 The patient should be instructed in self-monitoring of her DRA.174 A diastasis correction exercise can be performed to maintain alignment and discourage further separation. The exercise is performed in the supine hook-lying position (if tolerated and not contraindicated). With the arms crisscrossed over the abdomen, the patient manually approximates the recti muscles toward midline, performs a posterior pelvic tilt, and slowly exhales while lifting her head so that the scapulae clear the surface.166,175 In addition, the patient can perform any exercise that does not stress the sacroiliac joint or increase intra-abdominal pressure including leg sliding (see Chap. 28), abdominal isometrics with lower extremity movements, supine bridging (see Chap. 28), quadruped leg raising (see Chap. 28), modified squats (see Chap. 28), and posterior pelvic tilts (see Chap. 28) while using hands to support the abdominal wall.174 Maintaining the stability of the pelvis and decreasing the DRA are the goals for exercise progression.174 Educating the patient about proper body mechanics and posture is necessary to prevent undue stress on the back and a DRA during the postpartum phase.174

Neurologic

Swelling and increased fluid volume can cause symptoms of thoracic outlet syndrome due to compression of the brachial plexus, carpal tunnel syndrome due to median nerve compression, or meralgia paresthetica, which is compression of the lateral (femoral) cutaneous nerve of the thigh.176–178

Pregnancy-related depression and postpartum depression has been documented to occur in 5–20% of all postpartum mothers179–181 but can also occur in fathers.182 These disorders can range from a mild “postpartum blues,” which occurs from 1–5 days after birth and lasts for only a few days, to the more severe forms that include postpartum depression and postpartum psychosis, which require medical or social intervention.183–185

Gastrointestinal

Nausea and vomiting may occur in early pregnancy and are generally confined to the first 16 weeks of pregnancy but occasionally remain throughout the entire 10 lunar months (hyperemesis gravidarum).183,186–189 The causes of hyperemesis gravidarum are largely unknown.

Cardiopulmonary System

The pregnancy-induced changes in the cardiovascular system develop primarily to meet the increased metabolic demands of the mother and fetus. These changes include the following:

• A predominance of costal versus abdominal breathing as the diaphragm elevates with a widening of the thoracic cage.
• Mild increases in oxygen consumption due to increased respiratory center sensitivity and drive.190 Even with mild exercise there is a greater than normal increase in respiratory frequency and oxygen consumption to meet the greater oxygen demand.190 However, pregnant women demonstrate decreased respiratory frequency and maximal oxygen consumption as exercise increases to moderate and maximal levels.190
• A compensated respiratory alkalosis.191
• A low expiratory reserve volume.190,192
• Increased blood volume: The blood volume increases progressively from 6–8 weeks of gestation (pregnancy) and reaches a maximum at approximately 32–34 weeks with little change thereafter.193 The increased blood volume serves two purposes:194,195
  • To facilitates maternal and fetal exchanges of respiratory gases, nutrients, and metabolites.
  • To reduce the impact of maternal blood loss at delivery.
• Increased plasma volume is relatively greater than that of red cell mass resulting in hemodilution and a decrease in hemoglobin.194,196,197
• Increased cardiac output. This increases to a similar degree as the blood volume.194,195

During pregnancy, a condition called supine hypotension (also known as inferior vena cava syndrome), manifested by a decrease in blood pressure (BP), may develop in the supine position, especially after the first trimester. The drop in BP is thought to be caused by the occlusion of the aorta and inferior vena cava by the increased weight and size of the uterus as spontaneous recovery usually occurs upon change of maternal position. However, although a change in position is necessary, patients should not be allowed to stand up quickly to avoid another condition related to a decrease in blood pressure; orthostatic hypotension. Signs and symptoms of this condition run the gamut from headache, bradycardia, dizziness, and shortness of breath to numbness in extremities, nausea and vomiting, and syncope (fainting). Ideally, the time spent in supine should be limited to approximately 5 minutes. Alternative positions include side lying (best position for minimizing compression), supine reclined, or supine with a small wedge under the right hip.

Metabolic System

The metabolic rate increases during both exercise and pregnancy, resulting in greater heat production. Fetoplacental metabolism generates additional heat, which maintains fetal temperature at 0.5–1°C (0.9–1.8°F) above maternal levels.198–200 Because of the increased demand for tissue growth, insulin is elevated from plasma expansion and blood glucose is reduced for a given insulin load. Fats and minerals are stored for maternal use.

Gestational diabetes is defined as carbohydrate intolerance of variable severity, with onset or first recognition during pregnancy. After the birth, blood sugars usually return to normal levels; however, frank diabetes often develops later in life. Typical causes include

• genetic predisposition;
• high-risk populations include people of Aboriginal, Hispanic, Asian or African descent;
• family history of diabetes, gestational diabetes, or glucose intolerance;
• increased tissue resistance to insulin during pregnancy, due to increased levels of estrogen and progesterone.

Current risk factors include

• maternal obesity (>20% above ideal weight),
• excessive weight gain during pregnancy,
• low level of high-density lipoprotein cholesterol (<0.9 mmol/L) or elevated fasting level of triglycerides (>2.8 mmol/L),
• hypertension or preeclampsia (risk for gestational diabetes is increased to 10% to 15% when hypertension is diagnosed),
• maternal age >25 years.

Most individuals with gestational diabetes are asymptomatic. However, subjectively the patient may complain of

• polydipsia,
• polyuria,
• polyphagia,
• weight loss.

Renal and Urologic Systems

Anatomic and hormonal changes during pregnancy place the pregnant woman at risk for both lower and upper urinary tract infections and for urinary incontinence.183 As the fetus grows, stress on the mother's bladder can increases. This can result in urinary incontinence (refer to “Urinary Incontinence”).

Exercise Prescription

The goals of therapeutic exercise during pregnancy are to improve muscle balance and posture, help provide support of the growing uterus, stabilization of the trunk and pelvis, and maintenance of function for more rapid recovery after delivery.175 Contraindications to exercise include the following:201

• An incompetent cervix (early dilation of the cervix before pregnancy is full-term)
• Vaginal bleeding (especially second or third trimester)
• Placenta previa (the placenta is located on the uterus in a position where it may detach before the baby is delivered)
• Multiple gestation with risk of premature labor
• Pregnancy-induced hypertension
• Premature labor (labor beginning before the 37th week of pregnancy)
• Maternal heart disease
• Maternal type I diabetes
• Intrauterine growth retardation

Even without these conditions, the patient requires permission from her physician before beginning an exercise program. Some precautions should be observed during exercise (Table 30-4)202–209 Warning signs associated with exercise during pregnancy include pain, vaginal bleeding, tachycardia, dyspnea, uterine contractions, and chest pain.210

Exercise programs for high-risk pregnancies should be individually established based on diagnosis, limitations, physical therapy examination and evaluation, and in consultation with the physician. Exercises for the pelvic floor are described in “Urinary Continence.”

Adjunctive Interventions

Modalities that increase body heat (hot packs, ultrasound, shortwave or microwave diathermy) should be used with caution, especially over the abdomen or uterus. Except for the use of transcutaneous electrical stimulation during labor and delivery, electrical stimulation is contraindicated during pregnancy.

Urinary Incontinence

Urinary incontinence includes the various types of incontinence: stress incontinence (a loss of bladder control associated with increased abdominal pressure that occurs during coughing or exercise), urge incontinence (a sudden urge to urinate), or mixed incontinence (a combination of stress and urge incontinence).211 One of the contributing factors to urinary incontinence can be a weakness of the pelvic floor musculature. The various types of urinary incontinence are described in Table 30-5. Stress incontinence has prevalence rates that range from 10 to 55% in 15- to 64-year-old females.212 Although often associated with aging, incontinence due to PFM weakness is not an automatic response to aging and many patients have achieved significant improvement through behavior modification, muscle reeducation, and PFM (see Chap. 29) strengthening.213,214 Behavior modification techniques include timed voiding schedules, proper toileting techniques, dietary modification, and patient education. Muscle reeducation is primarily used for those patients who do not demonstrate improvement with the PFM strengthening program after approximately 4 weeks. Muscle reeducation can be achieved in a number of ways:

• Biofeedback. A study by Cardozo et al.215 reported improvements in 81% of patients with urge incontinence who were treated with biofeedback.
• Acupuncture. A study by Philp et al.216 reported improvements in 77% of patients with urge incontinence who were treated with acupuncture.
• Electrical stimulation. Various forms of electrical stimulation have been used in the treatment of female urinary incontinence. Electrical stimulation is an option for patients who demonstrate difficulty with identifying the PFMs or with producing a contraction of these muscles. Transvaginal stimulation with a removable electrode has been in clinical use in Europe and North America for three decades. The typical neuromuscular stimulation system is a portable electrical pulse generator powered by a 9-V alkaline battery. A fully insertable vaginal electrode, which is composed of silicone rubber, is commonly used. Two randomized studies have reported the usefulness of transvaginal electrical stimulation.217,218 In the study by Sand et al.,217 comparisons of changes from baseline between active-device and control patients showed that active-device patients had significantly greater improvement in weekly (p = .009) and daily (p = .04) leakage episodes, pad testing (p = .005), and vaginal muscle strength (p = .02) when compared with control subjects. Significantly greater improvement was also found for both visual analog scores of urinary incontinence (p = .007) and stress incontinence (p = .02), as well as for subjective reporting of frequency of urine loss (p = .002), and urine loss with sneezing, coughing, or laughing (p = .02), when compared with controls. In the Smith et al.218 study, of the patients using electrical stimulation in the stress urinary incontinence group, 66% improved and 72% of the patients with detrusor instability treated with electrical stimulation improved. These rates were not considered statistically significant when compared to traditional therapy, but the authors concluded that electrical stimulation was as safe and at least as effective as properly performed Kegel and drug therapy in the treatment of stress urinary incontinence and detrusor instability. A typical protocol is outlined below:219
  • For patients with urge incontinence: 12.5 Hz for 15 minutes twice a day.
  • For patients with stress incontinence: 50 Hz for 15 minutes twice a day.
  • For patients with mixed incontinence: 12.5 Hz for 15 minutes a day and 50 Hz for 15 minutes a day.

In 1948, Kegel first advocated PFM exercise to enhance urethral resistance and promote urinary control.220 The application of Kegel exercises has been broadened to various applications, but the concentration continues to be considered a useful adjunct in the management of functional urinary incontinence.211 Many studies have shown that the success of PFM exercise for female stress urinary incontinence depends on the degree and duration of treatment and close supervision by a PT.221 The patients are initially educated in PFM awareness. Several teaching methods can be used, including verbal cues, visualization with an anatomical model, palpation, objective PFM contraction at the anus, or biofeedback with electromyography recordings via a rectal probe.222 The method chosen depends on the patient's baseline awareness, coordination, and comfort level. The palpation method is performed as follows:

The patient is asked to sit forward on a chair with their legs apart, their spine extended, and their feet flat on the floor. The clinician and patient each place a hand anterior to the ASIS and along the inguinal region to feel the contraction of the transverse abdominis and the internal obliques. The fingers are also spread superiorly to feel the weight of the belly and the RA. The patient is asked to “move the urethra and vagina gently upward” and to maintain the contraction for endurance.

Bracing

The patient is asked to sit forward on a chair with their legs apart, their spine extended, and their feet flat on the floor. The patient is asked to “push their abdomen out” without using an inspiratory effort and to isometrically contract the upper and lower RA in its outer range. The patient is taught to initiate, and hold, this action during a defecatory urge.

Abdominal Drawing-In

The patient is positioned in supine with the spine in neutral and the abdominal wall relaxed. The patient is asked to draw the lower part of the abdomen up and in toward the spine without moving the trunk or pelvis, or using an inspiratory effort, thereby contracting the transverse abdominis and the internal obliques. This exercise is taught in a variety of patient positions, with the appropriate muscles being palpated by the patient and clinician and the use of normal breathing.

Other exercises are added as tolerated. For the following four exercises the patient is positioned in the supine, hook-lying position221:

• Exercise 1. The patient performs a PFM contraction with a posterior pelvic tilt.
• Exercise 2. The patient performs a PFM contraction with a bridging motion.
• Exercise 3. The patient performs a PFM contraction with hip adduction against a pillow between the knees.
• Exercise 4. The patient performs a PFM contraction with hip external rotation against an elastic exercise band.

Swiss ball exercises may then be added.221,223 The patient is positioned sitting on a Swiss ball:

• Exercise 1. The patient performs a PFM contraction with a posterior pelvic tilt in the sagittal plane while rolling on the ball.
• Exercise 2. The patient performs a PFM contraction with a posterior pelvic tilt in the oblique plane while rolling on the ball.
• Exercise 3. The patient bounces vertically on the ball, while performing a PFM contraction during each ascending movement.
• Exercise 4. The patient performs a PFM contraction while rolling on the ball from sitting to standing for functional training with transfers.

Medical management of urinary incontinence is aimed at prevention and may include the following:

• Nutritional counseling to help prevent constipation and to encourage adequate hydration.
• Medications to relieve urge incontinence: estrogen replacement therapy, anticholinergics, alpha-adrenergic blockers to increase bladder outlet/sphincteric tone, antispasmodics, and combination therapy with tricyclic antidepressant agents and antidiuretic hormone.224–228
• Surgical intervention can include catheterization, and surgically implanted artificial sphincters and bladder generators (sends impulses to the nerves to control the bladder function).

Menstruation

Normal menstrual cycles are defined by three phases, all of which are governed by alterations in blood levels of estrogen and progesterone:

• Follicular. Ovarian-produced estrogen increases resulting in endometrial growth, characterized by a compact, proliferative stroma, and increases in endometrial glands in number and length.
• Ovulatory. Ovulation produces the corpus luteum that leads to the production of estrogen and progesterone with progesterone-stimulated production of a secretory endometrium.
• Luteal. The endometrium acquires an edematous stroma with glands that are tortuous and dilated. In the absence of pregnancy, the corpus luteum becomes atretic with a resultant sudden drop in hormonal levels of estrogen and progesterone and then menstruation.

Menarche, or the onset of menstrual periods, normally develops between ages 9 and 16 years in the United States with 12.4 years as the mean age for menarche.229 The development of menarche is under many influences, including nutritional status, intensity exercise patterns, weight, race, genetic factors, and others.

Abnormal menstrual cycles include the following:

• Amenorrhea: absence of menses.
• Oligomenorrhea: infrequent, irregular bleeding at >45 day intervals.
• Menorrhagia/hypermenorrhea: prolonged or excessive uterine bleeding occurring at regular intervals.
• Metrorrhagia: uterine bleeding occurring at irregular but frequent intervals, the amount being variable.
• Menometrorrhagia: prolonged uterine bleeding occurring at irregular intervals.

The effect of exercise on the severity of menarche is inconclusive. However, the side effects of menarche including menstrual pain, edema, bloating, and other symptoms may have a negative impact.

Breast-Cancer-Related Lymphedema

The lymphatic system is comprised of strategically placed lymph nodes connected by a network of lymphatic vessels, which act as the circulatory system for the immune system. Larger lymph collectors, known as trunks or ducts, handle these larger volumes of lymph fluid. The majority of the lymph produced by the body in a 24-hour period (2–4 L) returns to the heart. As lymph fluid moves more centrally, the diameter of lymph vessels increases. The major lymph nodes are the submaxillary, cervical, maxillary, mesenteric, iliac, inguinal, popliteal, and cubital nodes. Lymphedema results from a mechanical insufficiency that arises in an area, when lymph collectors sustain functional and structural damage. Breast-cancer-related dysfunction of the lymphatic system and subsequent lymphedema of the upper extremity can occur as a complication of the treatment for breast cancer. Current treatment for breast cancer usually involves removing a portion or all of the breast accompanied by excision or radiation of the adjacent axillary lymph nodes, the principal site of regional metastasis.230 In addition to upper extremity lymphedema, other complications include loss of shoulder mobility and limited function of the arm and hand.231

The other impairments and complications that may occur in association with the treatment of breast cancer are listed in Table 30-6230 The most common method to diagnose and measure upper extremity (UE) lymphedema is circumferential measurements using specific anatomical landmarks to estimate volume differences between the affected and unaffected extremities. A more accurate measure of volume difference is the water displacement technique using a volumeter.

The intervention for breast-cancer-related lymphatic dysfunction includes the following:230

• Strengthening exercises. Exercise encourages muscle contractions to provide the primary pumping mechanism for lymphatic and venous drainage. Progressive resistance training (using light weights initially and progressing as tolerated) for the major muscle groups of the upper trunk and upper extremity are emphasized (e.g., seated row, bench press, latissimus dorsi muscle pull-down, triceps muscle extension, and biceps curl).232
• Aerobic exercises. After 2 weeks, an arm ergometer can be introduced as an upper-body aerobic exercise. Moderate-intensity aerobic conditioning exercises are added as tolerated.
• ROM exercises. Individualized shoulder (Chap. 16) and cervical (Chap. 25) ROM exercises to address any muscle imbalances.
• Massage and wrapping. Various types of specialized wrapping, taping, and lymphedema massage are advocated, followed by pressure garment wear.

Although traditionally popular, pneumatic compression devices are not currently prescribed for lymphedema because the natural drainage system has been damaged, and these devices can potentially cause more stress to an already-damaged system.