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PHYSIOTHERAPY IN PAEDIATRICS

OVERVIEW OF
NEURO MUSCULAR CONDITIONS
G P KUMAR
PROFESSOR,
COLLEGE OF PHYSIOTHERAPY,
SUMANDEEP VIDYAPEETH,
VADODARA, GUJARAT
Lower Motor Neuron comprises
AHC
Nerve Root
Plexus
Nerve

Neuro Muscular Junction


Muscles
Common Paediatric Neuromuscular
conditions
AHC
Anterior Poliomyelitis
Spinal Muscular atrophy
Nerve Root
Guillain-Barr syndrome (GBS)
Nerve
Hereditary Sensory Motor Neuropathies
Neuropathies (infection / toxic)
Neuro Muscular Junction
Myesthenia Gravis
Muscles
Muscular dystrophies DMD, BMD
Polymyositis
Impairments in Neuro Muscular
conditions
Primary impairment
Muscle weakness
Secondary impairments
Wasting
Denervation
Disuse
Reduced ROM
Deformities
Imbalance in muscle forces
Reduced function in tasks
Ambulation
Increased Fatigue
Reduced QOL
Impairments Assessment
Muscle weakness
Wasting
Reduced ROM Manual muscle testing (Serial)

Deformities


Goniometry (ROM)

Muscle length assessment

Reduced function in Functional assessment

tasks Gait assessment


Endurance assessment
Ambulation
Increased Fatigue
Impairments Management
Muscle weakness
Wasting
Muscle strengthening
Reduced ROM Electrical stimulation

Deformities


Stretching

Splinting

Reduced function in Orthosis

tasks Functional training


Gait training
Ambulation Energy conservation

Increased Fatigue
Challenges in Neuro Muscular
conditions
Primary Impairment - Muscle weakness, same in all conditions

BUT..
Natural History of disease
Features and progression of diseases

Variability in time
Acute, Chronic

Variability in affecting structures


Upper limbs, lower limbs
Proximal and distal muscles
Patchy or total limb
Common Paediatric conditions
AHC
Anterior Poliomyelitis
Spinal Muscular atrophy
Nerve Root
Guillain-Barr syndrome (GBS)
Nerve
Hereditary Sensory Motor Neuropathies
Neuropathies (infection / toxic)
Neuro Muscular Junction
Myesthenia Gravis
Muscles
Muscular dystrophies DMD, BMD
Polymyositis
Challenges in Pediatric Neuro
Muscular conditions
Child is growing

Growth of skeletal system depends on Muscle force


Impairment of muscle weakness impairs skeletal growth
Limb length discrepancies

Other Musculo skeletal complications


Orthosis, aids and wheel chair require constant revision and
upgradation
Pulmonary complications
Anterior Poliomyelitis
Acute

Convalescence

Post polio residual paralysis (PPRP)

Post Polio Syndrome


Acute Polio
Inflammation in progress, muscles are tender

Patient positioning in correct anatomic alignment

Frequent turning

Passive range of motion exercises

Moist heat application for muscle pain


Convalescent stage
Period of recovery

Attainment of maximal recovery in individual muscles


Strengthening exercises
Avoiding fatigue of weak muscles
Restoration and maintenance of normal joint ROM
Prevention and correction of deformities
Stretching and splinting
Readjustment to cater for growth
PPRP
No more recovery

To concentrate on increase
available strength

To prevent further deterioration in


ROM, deformities

To teach to use all available


muscles to perform tasks
Orthosis in Polio
To support
Protect overstretching of weak muscle

To substitute
Replace paralysed muscle

To correct
Stretch shortened muscles
Surgery in Polio
Performed for correction of paralytic deformities

Fasciotomy Tensor fascia Lata and Ilio tibial band


release

Tendon transfer for foot drop

Arthrodesis
Spinal Muscular Atrophy
Type II Kugelberg Welander

Normal life expectancy

Ambulant up to adolescence, wheel chair adult


Guillain Barre Syndrome (GBS)
Demyelination or axonal loss or both

With or without Bulbar involvement

Only Motor or both motor and sensory involvement

Level and severity of involvement

Time for recovery


Guillain Barre Syndrome (GBS)
Acute phase

Plateau of variable length

Recovery phase lasting weeks to months


Duchennes Muscular Dystrophy
(DMD)
X linked recessive, inherited, progressive

Ambulatory stage

Wheel chair stage

Bedridden stage
Ambulatory stage
Strengthening and endurance exercises

ROM, deformity prevention

Prolonging the ambulation

Orthosis and walking aid use


Helpful in standing and walking but poor evidence for prolongation of ambulation

Bakker JPJ, de Groot IJM, Beckerman H, de Jong BA, Lankhorst GJ. The effects of knee-ankle-foot orthoses in
the treatment of Duchenne muscular dystrophy: review of the literature. Clin Rehabil 2000; 14: 34359
Wheel chair stage
Wheel chair prescription

Scoliosis prevention

Chest Physiotherapy

Functional independence
Bedridden stage
Chest physiotherapy

Bed mobility

Functional independence
Polymyositis
Weakness caused by immune responses in and around
the muscle fibre

Pain while exercising

Potential recovery

Avoid fatigue
Evidences
Exercises
Improves strength
Carried over to function?

Deterioration in strength?
moderate resistance or aerobic training regimes did not give
rise to deteriorations in strength
Very high-intensity resistance training No specific evidence
for deterioration still better to avoid to protect joints and
avoid over working
Electrical stimulation - Evidences
Direct muscle stimulation to the denervated quadriceps
have found improvements in muscle mass and force
production

Carry over to function little evidence


Orthosis - Evidences
In Charcot Marie Tooth disease (HSMN) Ankle foot orthosis
Reduces foot drop
Improves standing balance
Reduces general exertion

In DMD Knee Ankle Foot orthosis


Assist in standing and walking
Improving functional walking ability???

In Polio
Lighter orthosis reduces oxygen consumption and physiological cost
Remember.
Primary impairment in Neuromuscular conditions is
Muscle weakness

Neuro Muscular conditions differ in


Natural history Progression, recovery
Pathological changes
Structure that is involved
Presenting time

Child is growing, requirement differs at different times


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