PTPM008 PTM of Oncology and Palliative Care-related Medic…

PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008 Revision: 01 Page: 1 of 47

PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE

CARE-RELATED PATIENTS

NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.

Medicine: it’s a noble profession, it serves humanity

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PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS

SPEC. BY: Abdulrehman S. Mulla DATE: 04/09/2009 REVISION HISTORY REV.

DESCRIPTION

CN No.

BY

DATE

01 Initial Release PT0008 ASM 04/09/2009






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TABLE OF CONTENTS PAGE ONCOLOGY: 4 1.0 MEDICAL ONCOLOGY: 6 2.0 SURGICAL ONCOLOGY: 7 3.0 RADIATION ONCOLOGY: 8

3.1 BASIC PRINCIPLES OF RADIOTHERAPY: 9 3.1.1 SIDE EFFECTS: 9 3.1.2 WHILE AT THE HOSPITAL EXCEPT THE FOLLOWING: 11 3.1.3 DURING IMPLANT SURGERY: 12 3.1.4 DURING EXTERNAL BEAM THERAPY: 12

4.0 PEDIATRIC ONCOLOGY: 13 4.1 BONES, JOINTS AND MUSCLES: 20

4.1.1 TRAUMA INJURIES: 20 4.1.2 GAIT PROBLEMS: 20

4.2 DEVELOPMENTAL DISORDERS: 21 4.2.1 DEVELOPMENTAL DYSPLASIA: 21 4.2.2 OTHER RISK FACTORS MAY INCLUDE THE FOLLOWING: 23

A. SPECIFIC TREATMENT FOR DDH WILL BE DETERMINED BY YOUR BABY'S PHYSICIAN BASED ON:................. 24 I. PLACEMENT OF A PAVLIK HARNESS: 24 II. TRACTION AND CASTING: 24 III. SURGERY AND CASTING: 24 IV. SHORT LEG HIP SPICA CAST: 24 VI. WHEN TO CALL YOUR BABY'S PHYSICIAN: 25

4.3 BRAIN & NERVOUS SYSTEM: 26 4.3.1 CEREBRAL PALSY (CP): 26 4.3.2 HEAD INJURIES: 28

A. CAUSES OF MICROCEPHALY MAY INCLUDE: ............................................................................................................ 28 4.4 SYSTEM & LUNG: 30

4.4.1 CHRONIC FATIGUE SYNDROME: 30 A. SUGGESTED EXERCISES FOR CFS:............................................................................................................................ 31

4.5 JUVENILE CHRONIC ARTHRITIS: 33 4.5.1 PHYSICAL THERAPY: 34

A. SPLINTING:...................................................................................................................................................................... 34 B. JRA LONG-TERM CONCERNS:...................................................................................................................................... 34

I. COPING WITH JRA: 35 4.6 LUPUS: 36

4.6.1 PHYSIOTHERAPY FOR LUPUS: 37 4.7 RESPIRATION: 38

4.7.1 ASTHMA: 38 A. COMMON SYMPTOMS OF ASTHMA INCLUDE: ........................................................................................................... 38 B. PHYSIOTHERAPY ASSESSMENT: ................................................................................................................................ 38

I. YOUR CHILD’S MEDICATION: 38 C. TREATMENT TECHNIQUES FOR AN ASTHMA ATTACK: ............................................................................................ 39

I. TURNING: 39 II. COUGHING: 39 III. DEEP BREATHING: 39 IV. POSTURAL DRAINAGE: 39 V. PERCUSSION: 39 VI. VIBRATION: 39 VII. PREPARATION: 40 VIII. AFTERCARE: 40 IX. RISKS: 40 X. NORMAL RESULTS: 40

4.7.2 CYSTIC FIBROSIS: 41 A. POSTURAL DRAINAGE AND CPT:................................................................................................................................. 42

I. PURPOSE: 42 II. CHEST PHYSICAL THERAPY POSITIONS FOR INFANTS AND CHILDREN: 43






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1. UPPER LOBES: ............................................................................................................................................... 43 2. LOWER LOBES: .............................................................................................................................................. 43

III. PRECAUTIONS: 44 IV. DESCRIPTION: 44 V. TURNING: 44 VI. COUGHING: 44 VII. DEEP BREATHING: 44 VIII. POSTURAL DRAINAGE: 44 IX. PERCUSSION: 45 X. VIBRATION: 45 XI. PREPARATION: 45 XII. AFTERCARE: 45 XIII. RISKS: 45 XIV.NORMAL RESULTS: 45

4.8 PEDIATRIC PHYSIOTHERAPY: 47






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ONCOLOGY & PALLIATIVE CARE: ONCOLOGY:

Oncology, at its most basic level, involves the diagnosis and treatment of cancer. The word oncology comes from the Greek word meaning "mass" or "bulk," referring to tumors. A doctor who specializes in oncology is called an oncologist.

Oncology involves a huge range of study. Since cancer can occur in so many of the body's systems, many doctors choose to specialize in a particular branch of it, such as bone cancer or blood diseases. Some doctors specialize in chemotherapy treatments, while others focus on radiation therapy. Most doctors who specialize in oncology serve internships and residencies that focus on cancer treatment, usually in their preferred branch of therapy. A specialist often serves about four years beyond the normal residency period.

Oncology also involves research into cancer, its causes and possible cures. This is also a wide-open field for scientists interested in a variety of research opportunities. Oncology researchers continue to look for ways to treat even the rarest forms of cancer in humans.

Oncology has come a long way since early surgeons were able only to excise tumors with the most primitive means. It has leaped forward even in the past 25 years or so, with huge improvements in prevention, diagnosis and treatment. Doctors agree that early detection, if not prevention, is the best way to deal with cancer, and oncology also covers this facet of medicine. From this philosophy, tests like the Prostate-Specific Antigen panel have come into being. This test alone has saved countless men through early detection of prostate cancer or pre-cancerous conditions. Other exams, such as mammograms, represent huge strides in the early detection and treatment of breast cancer, while the Pap smear assists in early diagnosis of cervical cancer.

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






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

1.0 MEDICAL ONCOLOGY: Medical oncology is the specialty of internal medicine that deals with the diagnosis and, more specifically, the

management of the treatment of cancer. A medical oncologist is an internist who has completed a one-year internship followed by a three year residency in

oncology and internal medicine. He or she has knowledge of all aspects of the treatment of cancer including chemotherapy, surgery, radiation therapy, and biological therapy. In practice it is the medical oncologist who determines the proper choice of drugs and the dosage and schedule of drugs to be given. Consultation with radiation therapists and surgeons is frequent so that chemotherapy can be combined with these modalities when it can offer the best outcome.

The medical oncologist usually is the manager of the care of a cancer patient. Expertise in pain management, the medical oncologist considers treatment of chemotherapy side effects, psychological care, and social needs all. A medical oncologist may have a special interest in certain types of cancer or certain therapies such as biological therapy. But, the medical oncologist has the training, experience, and skills for finding out the latest information on all forms of cancer and all types of therapy.

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






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2.0 SURGICAL ONCOLOGY: "Surgical Oncology" refers to surgery for cancer. As board certified general surgeons, we are trained in nearly all-

major organ resections for cancer. In addition, we are aware of the options for chemotherapy and radiation therapy and whether they should be given

before or after the operation. We work closely with medical and radiation oncologists to provide you with optimal care.






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3.0 RADIATION ONCOLOGY: Radiation oncology, also called radiation therapy or therapeutic radiology, is a specialty of medicine that uses

various forms of radiation to treat disease, especially various cancers. In contrast, diagnostic radiology employs X-rays and other modalities for diagnostic imaging.

Radiotherapy or radiation treatment is defined as the treatment of diseases (mostly malignant) with ionizing radiation. The various types of ionizing radiation are X-rays, gamma rays, electrons; neutrons etc. but rays and high energy X-rays are in common practice. Ionizing radiation are capable of damaging the genetic material (DNA) in vivo without significant deleterious effects on normal tissues. Usually, X-rays are generated from X-ray tube of a Lineal Accelerator and rays from TeleCobalt unit. Radiation can cure or control cancer by inhibiting the cancer cells from dividing or reproducing. About fifty to sixty percent of patients with cancer will require radiation at sometime or other during the course of their disease. Radiation is a safe and effective form of treatment for patients of all ages.

Radiation oncology is relatively a new subject as compared to other medical specialties. However, there is no other medical field which had more speedy evolution than radiation oncology. Within a short span, it has attained tremendous growth and made a place for itself in the medical science showing its utility in the welfare of mankind. Almost a century ago, Famous German physicist, Wilhelm

Conrad Roentgen discovered the X-rays on 8th November 1895. Soon after the discovery of X-rays, Henry Beqerral in 1896 and Radium by Madame Curie discovered radioactivity in 1898. Radiation was used for treatment of cancer as early as in 1898. Since then, the field of radiation oncology has come a long way. With growing technology and better understanding of radiation biology, radiotherapy achieved many milestones at a faster speed. Since early 1990s, radiation oncology has increasingly become technology oriented. This has resulted in accurate target localization and precise delivery of radiation to the target area resulting into better tumor control, minimal normal tissue complications and to some extent improved survival rates.






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3.1 BASIC PRINCIPLES OF RADIOTHERAPY: An understanding of the basic principles of radiotherapy is essential to the successful use of radiation

therapy. These include: The higher the dose of the radiation delivered to the tumor, higher the probability of the local control of the

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

Therapy (EBRT) or teletherapy denotes treatment of patient when the source of radiation lies outside the body. The various equipments of EBRT are Linear Accelerator,

3.1.1 SIDE EFFECTS: Because radiation is most damaging to cells that multiply rapidly, it typically affects rapidly growing

normal cells as well as the ones with cancer. Such cells are especially prevalent in the blood, hair, and bone marrow. Damage to these and other cells can lead to a variety of side effects: Eating Problems: Cancer and/or radiation therapy can destroy your appetite or leave you too tired

to eat. This can become a vicious circle: Without sufficient calories, you're likely to lose weight and become even more fatigued.

Blood Problems: If radiation damages your bone marrow, where the red blood cells are normally produced, you may develop anemia or bleeding problems. Production of infection-fighting white blood cells can also be disrupted, leaving you open to disease. If your white blood cell count drops too far, your doctor may order blood transfusions.

Brain Swelling: Radiation therapy in your head may lead to brain swelling (edema). This swelling can cause headaches, nausea, vomiting, seizures, and problems seeing, talking, thinking, or walking.

Chest Problems: If the radiation is near your lungs, you may develop a cough, either with mucus (a "productive" cough) or without it (a "nonproductive" cough). Coughing can become severe enough to keep you awake and lead to fatigue. You may also experience shortness of breath (dyspnea). This problem is a frequent result of pneumonitis, an inflammation in the lung, or fibrosis, the development of scar tissue in the lung.

Cystitis (sis-TI-tis): Bladder infections, known medically as cystitis, are also a danger. Symptoms include burning pain when you urinate, difficulty starting urination, a constant or sudden urge to urinate, frequent urination at night, a decline in the amount of urine, blood in the urine, and inability to hold urine.






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Diarrhea: If the radiation is near your intestines, diarrhea may develop 2 to 3 weeks after radiation begins and continue until the treatments are finished.

Fatigue: You may feel tired during and after each treatment. (However, most people are still able to keep working despite the fatigue.) Pain, infection, anemia, poor appetite, and depression can make the problem worse. Fatigue can persist for weeks or months after therapy is finished, but should eventually disappear.

Hair Loss: You may lose some or all of your body hair during the first 2 to 3 weeks of radiation therapy. It should start to grow back about 2 to 3 months after therapy is finished.

Mouth Problems: The skin inside your mouth and throat may become swollen and sore and develop a white coating of fungus called "thrush." Don't attempt to pull this coating off; your doctor can prescribe medicine to kill it. In addition, your saliva may become very thick and sticky, making it hard to talk and eat, and easier to develop cavities in your teeth. Food may start to taste bad, and you may not be able to taste some foods at all.

Stomach Problems: You may develop nausea or vomiting if your stomach or intestines are in the area of radiation. The attacks are usually brief, generally starting within 6 hours after radiation and continuing for 3 to 6 hours.

Skin Problems: The skin over the radiation area may become swollen and sore and may change color from light pink to red to brown. It may also become itchy, dry, or flaky. If the top layers of the skin peel off, the area may become sore and wet. Skin problems are also possible on the side of the body where the radiation exits.

Sexual Problems in Men: Radiation therapy can damage a man's testicles, lowering his sperm count or causing sterility. Men may also experience difficulty getting erections. These problems are sometimes temporary, but can also be permanent.

Sexual Problems in Women: A woman may have the symptoms of menopause (hot flashes, no periods) if her ovaries receive radiation, and may lose interest in sex. To reduce these side effects, your doctor may suggest surgery to move your ovaries out of the way of the radiation.






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3.1.2 WHILE AT THE HOSPITAL EXCEPT THE FOLLOWING: You may encounter the following procedures and equipment during your stay. Taking Vital Signs: These include your temperature, blood pressure, pulse (counting your

heartbeats), and respirations (counting your breaths). A stethoscope is used to listen to your heart and lungs. Your blood pressure is taken by wrapping a cuff around your arm.

Blood Tests: You'll need blood taken for tests before, during, and after radiation therapy. Samples can be drawn from a vein in your hand or from the bend in your elbow.

Blood Transfusion: If you have anemia (a shortage of red blood cells) or a low white blood cell count, you may need a transfusion. Although you might be worried about catching AIDS or hepatitis from tainted blood, the risks posed by going without a transfusion are actually much greater. Your chance of receiving infected blood is about 1 in a million; severe blood loss, on the other hand, can easily trigger a heart attack.

Anesthesia: If you're receiving a radioactive implant, you'll need a pain-killer during the operation. For this type of procedure, the following options are available:

Spinal Anesthesia: This type of anesthesia requires an injection in the spine. You will be awake during surgery but will be numb below the waist. Feeling will return in about 2 hours.

Epidural Anesthesia: For this type, a tiny tube is positioned near the spine, allowing administration of additional medication during the operation. You will be awake during surgery but will be numb below the waist. Feeling will return to your legs when the anesthesia wears off.

General Anesthesia: This alternative puts you completely to sleep throughout the operation. The anesthetic is given either as a liquid in your IV or as a gas through a facemask or endotracheal (END-o-TRA-kee-ull) tube placed in your mouth and throat.

Local Anesthesia: This is simply a pain-killing injection at the site of the operation. You'll remain awake, and may feel some painless pressure or pushing.

Intravenous Regional Anesthesia: This approach can be used on an arm or leg. A pressure cuff is first put on the limb, then painkillers are given through an IV. The cuff keeps the medication in the affected limb.






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3.1.3 DURING IMPLANT SURGERY: The doctor will make an incision close to the cancerous area, then insert into the tumor an implant

or an implant holder. The implant can take the form of a thin wire, a tube, or round marble. If a holder is inserted, radioactive material will be added after the surgery. The operation typically takes 1 to 2 hours.

3.1.4 DURING EXTERNAL BEAM THERAPY: The treatment schedule depends on the type of cancer, its location, and the state of your health.

Treatments can be as often as once or twice a day, 3 to 5 days a week. They can last from 2 to 8 weeks. Each treatment takes about 10 minutes, most of which time is spent positioning the radiation beam. A beam film (also called a check or portal film) may be taken to make sure the machine is positioned correctly. The beam causes no pain or any other sensation.






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4.0 PEDIATRIC ONCOLOGY: Pediatric oncology is usually recognized as a fourth, distinct discipline within the field of oncology. If your child or

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

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






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Dorsiflexion: Ankle movement, when the foot bendsupwards, towards the leg Eversion: Turning out (foot)

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






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

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






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

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

Plantar flexion: The movement when the ankle points downwards.






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Prone: Lying on the tummy

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

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

Supine: Lying on the back.






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

Symmetrical: Both sides equal






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Tone: Firmness of the muscles / Readiness to move

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

Voluntary Movements: Movements occurring with thought and intention






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4.1 BONES, JOINTS AND MUSCLES: Conditions affecting bones, joints and the tissues around them are described as ‘musculo-skeletal’ or

‘orthopedics’. Because there are many physiological and anatomical differences between children and adults, children

require a specialized approach to their orthopedic management. The physiotherapists at KidsPhysio always consider these differences when assessing and treating children. Some of the more common musculo-skeletal problems that affect children and teenagers include:

4.1.1 TRAUMA INJURIES: For example fractures, sprains or strains resulting from sports, falls, car accidents and other injuries.

When children’s bones break they look similar to a broken green branch from a tree, hence the name "greenstick fractures". Adult’s bones tend to have a well-defined break. The bones of children and young adolescents contain "growing zones" called growth plates or epiphyses. Special care needs to be taken if the fracture site is near to one of these growth plates. Children often need physiotherapy after breaking a bone to help to restore mobility and strength to the affected limb.

Strains occur when a muscle is over-stretched, often following inadequate warming up before sport or if the muscle is not used to a particular activity.

Sprains are an overstretching or a partial tear of the ligaments or tendons, and are usually the result of an injury, such as twisting an ankle or knee.

4.1.2 GAIT PROBLEMS: When children first start walking they will often walk on their toes or with their feet turned in. This is

quite normal, but usually improves by the time they are 6 or 7. Sometimes, as children grow, they develop an uneven walking pattern which can be improved with physiotherapy. Flat Feet are feet with a flattened arch. Flat feet can contribute to other problems such as knee and

hip pain and balance difficulties. Scoliosis is a name given to an abnormal ‘s’ shaped curve of the spine. Talipes is also called ‘club foot’. The ligaments and tendons around the foot and ankle are tight

when the baby is born, making the foot stiff to move. Physiotherapy stretches can help to restore the movement in the foot.

Erbs Palsy is also known as Brachial Plexus Paralysis. The primary nerves, that supply the movement and sensation to the arm, are partially or completely paralyzed causing weakness and limitation in movement. Physiotherapy helps to maximize the range of movement, strength and function of the affected arm.

Torticollis or ‘Wry Neck’ describes a condition where a tight sterno-mastoid muscle in one side of the neck limits a child’s neck movements. Positioning and physiotherapy stretches can help to gain full neck movements.

Hyper mobility describes when a child has an increased range of movement in joints. Arthritis is a disease involving the immune system. It causes inflammation of joints, causing

weakness and stiffness. Knee Problems are common in adolescents. Osgood-Schlatter disease is an inflammation of the

bone, cartilage, and/or tendon at the top of the shinbone. Chondromalacia Patella is characterized by pain under the kneecap.

Growing Pains are pains, generally in children’s or adolescent’s legs, often attributed to rapid growth.






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4.2 DEVELOPMENTAL DISORDERS:

Developmental pediatrics (child development) is concerned with the way children mature, from birth until adulthood.

Physiotherapists are mainly concerned with the development of body postures and large movements (gross motor skills). However, they need to understand the way children develop all their skills, including hearing, speech, vision, fine movements, social behavior and play, in order to assess or treat a child with suspected developmental problems.

Health visitors screen children for developmental problems at the 6-8 week, 8 month, 18-24 month, and 3 year checkups. If there are any concerns regarding a child’s development, if there were difficulties at birth or if a baby is premature, they may be referred to a pediatrician (a specialist children’s consultant) at a hospital or child development center.

If there are concerns regarding a baby’s or toddlers gross motor development, they will generally be referred for physiotherapy. Ideally, a child should start physiotherapy as early as possible. Physiotherapy can help babies develop from a very early age, by placing them in beneficial positions and helping them to move.

Early intervention therapy (EIT) has proven highly effective at helping improve developmental outcomes for children with delays. High-Risk Newborns - Developmental Dysplasia of the Hip (DDH)

4.2.1 DEVELOPMENTAL DYSPLASIA: Developmental dysplasia of the hip is a congenital (present at birth) condition of the hip joint. It

occurs once in every 1,000 live births. The hip joint is created as a ball and socket joint. In DDH, the hip socket may be shallow, letting the "ball" of the long leg bone, also known as the femoral head, slip in and out of the socket. The "ball" may move partially or completely out of the hip socket.

The greatest incidence of DDH occurs in first-born females with a history of a close relative with the condition.

Hip dysplasia is considered a "Multifactorial trait." Multifactorial inheritance means that many factors are involved in causing a birth defect. The factors are usually both genetic and environmental.

Often, one gender (either male or female) is affected more frequently than the other in Multifactorial traits. There appears to be a different "threshold of expression," which means that one gender is more likely to show the problem than the other gender. For example, hip dysplasia is more common in females than males.

One of the environmental influences thought to contribute to hip dysplasia is the baby's response to the mother's hormones during pregnancy. A tight uterus that prevents fetal movement or a breech delivery may also cause hip dysplasia. The left hip is involved more frequently than the right due to intrauterine positioning.

What are the risk factors for developmental dysplasia of the hip (DDH)? First-born babies are at higher risk since the uterus is small and there is limited room for the baby to

move; therefore affecting the development of the hip.






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4.2.2 OTHER RISK FACTORS MAY INCLUDE THE FOLLOWING: Family history of developmental dysplasia of the hip, or very flexible ligaments Position of the baby in the uterus, especially with breech presentations Associations with other orthopedic problems that include metatarsus adduct us, clubfoot deformity,

congenital conditions, and other syndromes The following are the most common symptoms of DDH. However, each baby may experience symptoms differently. Symptoms may include: The leg may appear shorter on the side of the dislocated hip The leg on the side of the dislocated hip may turn outward The folds in the skin of the thigh or buttocks may appear uneven The space between the legs may look wider than normal

A baby with developmental dysplasia of the hip may have a hip that is partially or completely dislocated, meaning the ball of the femur slips partially or completely out of the hip socket.

The symptoms of DDH may resemble other medical conditions of the hip. Always consult your baby's physician for a diagnosis.

Developmental dysplasia of the hip is sometimes noted at birth. The pediatrician or newborn specialist screens newborn babies in the hospital for this hip problem before they go home. However, DDH may not be discovered until later evaluations. Your baby's physician makes the diagnosis of developmental dysplasia of the hip with a clinical examination. During the examination, the physician obtains a complete prenatal and birth history of the baby and asks if other family members are known to have DDH. X-ray - a diagnostic test, which uses invisible electromagnetic energy, beams to produce images of

internal tissues, bones, and organs onto film. Ultrasound (Also called sonography.) - a diagnostic imaging technique which uses high-frequency

sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels.

Computed tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radio frequencies, and a computer to produce detailed images of organs and structures within the body.






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A. SPECIFIC TREATMENT FOR DDH WILL BE DETERMINED BY YOUR BABY'S PHYSICIAN BASED ON:

Your baby's gestational age, overall health, and medical history The extent of the condition Your baby's tolerance for specific medications, procedures, or therapies Expectations for the course of the condition Your opinion or preference

The goal of treatment is to put the femoral head back into the socket of the hip so that the hip can develop normally.

Treatment options vary for babies and may include: Anatomy of the hip joint

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

II. TRACTION AND CASTING:

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

III. SURGERY AND CASTING:

If the other methods are not successful, or if DDH is diagnosed after the age of 2 years, surgery may be required to put the hip back into place manually, also known as a "closed reduction." If successful, a special cast (called a spica cast) is put on the baby to hold the hip in place. The spica cast is worn for approximately three to six months. The cast is changed from time to time to accommodate the baby's growth and to ensure the cast's rigidity, as it may soften with daily wear.

The cast remains on the hip until the hip returns to normal placement. Following casting, a special brace and physical therapy exercises may be necessary to make the muscles around the hip and in the legs stronger.

IV. SHORT LEG HIP SPICA CAST:

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






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Check for cracks or breaks in the cast. Rough edges can be padded to protect the skin from scratches. Do not scratch the skin under the cast by inserting objects inside the cast. Use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot,

itchy skin. Never blow warm or hot air into the cast. Do not put powders or lotion inside the cast. Cover the cast during feedings to prevent spills from entering the cast. Prevent small toys or objects from being put inside the cast. Elevate the cast above the level of the heart to decrease swelling. Do not use the abduction bar on the cast to lift or carry the baby.

VI. WHEN TO CALL YOUR BABY'S PHYSICIAN:

Contact your baby's physician or healthcare provider if your baby develops one or more of the following symptoms: Fever Increased pain Increased swelling above or below the cast Drainage or foul odor from the cast Cool or cold toes

Long-term outlook for a baby with developmental dysplasia of the hip (DDH): While newborn screening for DDH allows for early detection of this hip condition, starting

treatment immediately after birth may be successful. Many babies respond to the Pavlik harness, traction, and/or casting. Additional surgeries may be necessary since the hip dislocation can reoccur as the child grows and develops. If left untreated, the baby may have differences in leg length, and may limp.






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4.3 BRAIN & NERVOUS SYSTEM: The nervous system is extremely complicated. The brain has often been likened to a central computer

within a vast, complicated network of wiring (the nervous system). The brain works at lightening speed making infinite decisions that affect the outcome of everything we do. It allows us to breathe, feel, talk, learn and remember, and enables us to move our bones and muscles in complicated yet coordinated ways. The brain allows us to perform all of these things and more, often without any conscious effort on our part, and even while we are asleep.

Unfortunately, such an amazing and complex system can go wrong. Damage can happen to the brain and nervous system before, during and after birth. Physiotherapy can help when damage occurs by helping the brain learn or relearn patterns of movement. Some of the children’s conditions treated by physiotherapists include:

4.3.1 CEREBRAL PALSY (CP): Is a condition primarily affecting a child’s motor development. It is caused by damage to the brain before, during or shortly after birth. Meningitis and Encephalitis are inflammatory conditions affecting the brain and spinal cord, usually

caused by bacteria or viruses. Meningitis is the inflammation of the coverings (‘meninges’) of the brain and spinal cord. Encephalitis is an inflammation of the brain tissue itself. Both conditions can result in permanent damage to the brain.

Spinal Cord Injury is caused by damage to the spinal cord. It can be caused from a direct injury to the cord itself or from an indirect injury from damage to the bones, soft tissues, and blood vessels surrounding the spinal cord. Only about 5% of spinal cord injuries occur in children. Symptoms of a spinal cord injury vary depending on the location and severity of the injury. The main problem is weakness of muscles and loss of sensation at and below the level of the injury.

Spina bifida is a congenital disorder affecting the formation of the spine. About 75% of cases are called ‘Myelomeningocele’. The backbone and spinal canal do not completely form before birth causing a decrease or lack of function of the parts of the body controlled from or below the defect. Most defects occur in the lower lumbar or sacral areas of the back (the lowest areas of the spine) because this area is normally the last part of th e spine to close during inter-utero development.






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Physical therapy is considered one of the mainstay therapies for cerebral palsy treatment. It is used to decrease spasticity, strengthen underlying muscles, and teach proper or functional motor patterns. A good physiotherapist will also teach the family and caregivers how to help the patient to help themselves.

Cerebral palsy physiotherapy generally consists of a few types of physical therapy. Physical therapy helps a cerebral palsy physiotherapy patient to improve their gross motor skills. Gross motor skills are those that utilize the large muscles in the body, such as those in the arms and legs. This cerebral palsy physiotherapy can help improve a patient's balance and movement.

Learning to walk, stand without aid, use a wheelchair or other adaptive equipment, and other movement skills can be greatly improved with cerebral palsy physiotherapy. Physical therapists help prevent further development of musculoskeletal problems in cerebral palsy physiotherapy patients.

They do this by preventing muscle weakening, deterioration, and contracture through proper cerebral palsy physiotherapy techniques. pressurized tank, can restore function to nerve cells that border the area of brain damage, rejuvenating them to a functional degree.

Unfortunately, all of these treatments are not available everywhere, nor are they necessarily going to be effective in each and every case of cerebral palsy treatment. Consult with your doctors and therapists, talk to people who have tried the treatment, and do your own research as well before deciding what cerebral palsy treatment is right for your child.

Cerebral palsy physiotherapy can start soon after diagnosis, and treatment is often more successful with early intervention.






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4.3.2 HEAD INJURIES: Head injuries are injuries to the brain caused by the head being hit by something or shaken violently. Head injuries are also called traumatic head or brain injury (TBI) and acquired brain injury (ABI). They can change how the person acts, moves and thinks. The signs of head injury can be very different depending on which part of the brain has been injured and how severely. Microcephaly is a neurological disorder where the baby’s head is much smaller than normal for an

infant of the same age and sex. It may be associated with other conditions or syndromes. Children with microcephaly may have learning difficulties and delayed development.

A. CAUSES OF MICROCEPHALY MAY INCLUDE:

Fetal alcohol syndrome Decreased oxygen to the fetal brain (cerebral anoxia) due to pregnancy complications or

complications during delivery Craniosynostosis — the premature fusing of the joints (sutures) between the bony plates that

form an infant's skull

Chromosomal abnormalities






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

In most cases, there's no specific treatment for microcephaly. Treatment is usually directed at managing the signs and symptoms associated with the disorder. If microcephaly due to craniosynostosis is detected early, treatment may include surgical opening of the sutures to let the brain grow normally.

If you're concerned about the size of your child's head, talk to your doctor. Doctors use growth rate charts — similar to those for height and weight — to compare your child's head circumference with that of other children of the same age and sex.

It's important to note that heads with circumferences in the 3rd, 2nd and even 1st percentiles are just small heads. Microcephaly is a head circumference that is significantly below the 1st percentile.






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4.4 SYSTEM & LUNG: Conditions that affect the whole body are called ‘systemic conditions’. Examples include chronic fatigue

syndrome, lupus and systemic juvenile arthritis. Specific and graded exercise programs have been shown to help the recovery of such problems. Respiratory conditions effect the lungs and air passages. Physiotherapist offers assessment, treatment and advice on respiratory conditions including asthma and cystic fibrosis.

4.4.1 CHRONIC FATIGUE SYNDROME: (CFS) is a condition that causes severe fatigue, which interferes with a person’s normal life? It

used to be known as ME (myalgic encephalomyelitis). It can affect any age group including school children and the elderly, but it most commonly affects

teenagers and young adults. In the past, doctors believed that chronic fatigue syndrome (CFS) was related to depression and

that the symptoms were "all in the mind". Whilst the condition remains poorly understood, most experts now agree that it is a distinct disease with physical symptoms. There are several hypotheses for the cause of CFS: CFS may develop following a viral or bacterial infection, for example glandular fever. (It is not the

same as the normal fatigue that often follows a bad infection like flu.) It may be linked to disorders that affect the body’s natural defenses (the immune system) or to

abnormalities of the hormonal system or the nervous system. Some doctors believe that there is a strong psychiatric or psychological element to CFS, and that

some cases it may be a form of depression. It may follow distressing life events such as bereavement. The main symptom of CFS is severe fatigue that lasts for over six months and does not improve

after rest. People who have CFS may also have other symptoms such as: Forgetfulness, memory loss, confusion, or difficulty concentrating Sore throat, Ender lymph nodes in the neck or armpits, Muscle pain, Joint pain without redness or swelling, Headaches, Unrefreshing sleep (waking up feeling tired or unrested) or trouble getting to sleep, Fatigue that lasts more than 24 hours after exercise or exertion at a level that the person was

previously able to manage without fatigue, Feeling hot or feverish even though temperature may be normal, Sensitivity to light or sound, Light-headedness or dizziness, when standing or sitting up from lying.

There is no specific test for diagnosing Chronic Fatigue Syndrome. It is usually diagnosed by using the history of symptoms and ruling out other possible conditions. When a doctor examines someone with CFS they usually find no abnormalities with their physical examination or blood tests.

Unfortunately, there is no simple cure for CFS. Most people who have CFS find that their symptoms get better over time and they are able to resume normal daily activity within 1 to 2 years. Some people will continue to have symptoms for many years.

KidsPhysio may be able to help by providing advice regarding appropriate exercise. We can look at your routines: including sleep patterns, which activities you are able to do / enjoy doing and what makes your symptoms better or worse. We will then discuss appropriate exercise, where possible, in the form of everyday activities, for example shopping, walking up and down stairs. Often specific strengthening






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or stretching exercises will also be beneficial. We will help you to keep an activity diary, so we can adjust the physiotherapy program to maximize its benefit. The diary will also help your doctor assess your progress. Your physiotherapist will liaise with the other members of the multidisciplinary team, eg doctor and psychologist.

A. SUGGESTED EXERCISES FOR CFS:

A person with CFS needs a gentle approach to physical activity and should only make tiny increases in the frequency, duration and intensity of their exercise program.

Be guided by your doctor or physiotherapist, but general suggestions include: Aim for no more than three exercise sessions per week. Experiment to find the type of exercise that works best for you. Choose from a range of gentle

activities such as stretching, yoga, Tai Chi, walking and lightweight training. Stretching seems to be well tolerated by people with CFS. You may prefer to perform your

stretching program while lying down in bed. Aerobic exercise seems to cause relapses for many people with CFS. If this is true for you, try

non-aerobic forms of exercise like weight training with lightweights. Keep an activity diary so you have a long-term picture of your performance levels and factors

that might impact on fatigue. Learn from past relapses. For example, if walking for 20 minutes worsened your symptoms, try

walking for five minutes and see how that goes. Use your activity diary to keep track of what works for you and what doesn’t.

Stop the physical activity well before you feel tired. Pacing yourself is very important. Remember that your exercise tolerance will differ from one day to the next. If possible, monitor your heart rate during exercise with a heart rate monitor or by manually

taking your pulse. Listen to your body – if you don’t feel up to exercising on a particular day, don’t. Slowly increase the intensity, time spent or frequency of exercise, but only when you know you

can cope with it. For example, if you can exercise for five minutes without suffering a relapse, try for six minutes.






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4.5 JUVENILE CHRONIC ARTHRITIS: Juvenile Chronic Arthritis is also known as juvenile rheumatoid arthritis, Still's disease, juvenile arthritis, and

juvenile chronic arthritis. It describes group of systemic inflammatory disorders that affect the joints of children under the age of 16 years.

The three major classifications are: Pauciarticular onset: Four or less joints are involved. This is the most common type of JIA (about 50% of

cases). Polyarticular onset: More than four joints are involved. Systemic onset: This type of JIA affects the whole

body and is associated with a fever and rash. It is estimated to affect 1 per 1000 children. Pauciarticular and polyarticular disease occur more frequently

in girls, while both sexes are affected with equal frequency in systemic onset disease. If you suspect that your child has a form of juvenile arthritis, it is very important to take them to your doctor.

The doctor may do a blood test to help him diagnose your child’s problem. It is natural for your child to want to sit still if they are in pain. However, it is important to get the right

balance between rest and exercise. A regular exercise program is essential. Muscles must be kept strong and healthy so they can help support and protect joints. Hydrotherapy can be very beneficial and KidsPhysio can help you arrange this.

Your child's doctor and physiotherapist will advise you about sports restrictions. Some sports, especially impact sports, can be hazardous to weakened joints and bones.

KidsPhysio can provide an appropriate program to manage your child’s arthritis. The physiotherapist will explain the importance of certain activities and recommend exercises suited to your child's specific condition. These may be range-of-motion exercises to restore flexibility in stiff, sore joints and other exercises to help build strength and endurance. The word "lupus" is Latin for "wolf." Back in the 1850's, physicians believed the rash that appears on the

face of lupus patients resembled the bite-mark of a wolf. "Erythematosus" is Latin for "red." The analogy to a wolf is an apt one: the wolf is a habitual creature (there is no cure for lupus), and it can sneak up on you and attack (you can feel great one minute and terrible the next).






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4.5.1 PHYSICAL THERAPY: A program of regular exercises, joint movement, and massage may help relieve symptoms and

prevent flare-ups. You and your child will work with a physiatrist (rehabilitation specialist) or a physical therapist to design this program. During flare-ups, physical therapy can help relieve symptoms.

A. SPLINTING: A splint worn over the affected joint may help protect the joint and relieve symptoms. If a splint is prescribed, it is usually worn only at home so the child doesn’t have to feel "different" in school or at play.

B. JRA LONG-TERM CONCERNS:

A child with JRA needs regular monitoring throughout childhood to help prevent problems. This includes regular eye exams and monitoring of the kidneys. The healthcare team will watch for growth problems in the affected joints. And the affected joints need continued checkups throughout the child’s life. Damage to the joint may eventually lead to the need for a joint replacement. Good management of symptoms and physical therapy can help the child avoid this damage.






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I. COPING WITH JRA: JRA can affect the child’s progress in school and social development. It also may affect

other members of the family. To help make things easier: Treat the child normally and the same as other siblings. Avoid giving the child with JRA

"special" treatment. Explain to the child that JRA is NOT his or her fault. Nothing he or she did caused the

disease. Follow all instructions and don’t change the treatment plan without talking to your child’s

doctor or other member of the healthcare team. Don’t make changes based on another parent’s suggestion—what works for one child may not work for another.

If prescribed medications cause side effects or don’t relieve symptoms, ask your child’s doctor about other choices.

Work closely with your child’s school to educate the teacher and the child’s classmates about JRA. Some children with JRA are absent from school for long periods during flare-ups. Work with your child’s school and teachers to help keep the child from falling behind. (For instance, keeping an extra set of textbooks at home may be an option.)

Encourage your child to participate in exercise and activities. Team sports or other group activities help keep the joints strong and flexible and also help the child develop social skills.

Look into joining a support group for parents and children with JRA. These groups give your child the chance to meet other children with JRA. They also allow you to talk to other parents who are coping with JRA.

Consider counseling for you and your child. Having a chronic disease can be very hard to deal with. Talking to a professional can help you and your child work through emotions like fear, sadness, and anger.






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4.6 LUPUS: Lupus is an autoimmune disease - which means that the child's immune system has created "auto-

antibodies" - and the immune system has begun to fight against the child's own body: organs, blood, bones and joints, and connective tissue. In children's words, the immune system is "confused" - it's supposed to protect you, but instead it's attacking you.

The immune system fights by inflammation. With internal inflammation, there may be no visible signs. If vital organs are repeatedly inflamed, irreversible damage can occur. When it becomes necessary to suppress the immune system, the child is susceptible to secondary conditions that can seriously complicate the picture

There are more people with lupus than there are with leukemia, cystic fibrosis, and multiple sclerosis combined, yet lupus receives less than 10% of the medical research dollars these better-known diseases receive. Unfortunately, there is no cure for this disease.

Think of how your thumb might feel with an infection - it would be painful, swollen and possibly throb - it would be difficult to ignore. Now imagine that many parts of your body feel like that thumb - all at the same time. Now imagine that you are a child, and you have a better idea of the obstacles families might face. Unless the child has the telltale facial redness or rash, they might appear perfectly healthy, while feeling like they've got a really bad case of the flu (fever, headache, joint pain, fatigue, nausea)... in a word, yukky.

It's been said that having lupus is like having a full-body transplant... and your body is rejecting the transplant.

When a child is diagnosed with lupus, the entire family's world can turn upside down.






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4.6.1 PHYSIOTHERAPY FOR LUPUS: Clinical features of SLE are extremely variable and may include disorders of skin, pulmonary and

cardiovascular systems, renal function, haematological conditions, neuropsychiatric problems, systemic symptoms, and important to physiotherapy, musculoskeletal symptoms. A migratory non-erosive arthritis, usually symmetrical, commonly affects the knees, wrists and proximal interphalangeal joints. The arthritis mainly consists of soft tissue swelling with little effusion. However, deformities may occur due to soft tissue contractures and joint subluxation. Tenosynovitis may lead to tendon rupture. Avascular necrosis of bone may occur, especially in the femoral head. This may be due to the disease itself or to high dose steroids used to treat the disease. Osteoporosis or muscle weakness may develop secondary to steroids. Myalgia is frequently found but myositis is not common.

Exercise programs for SLE should emphasize strengthening and low impact aerobic endurance workouts. Programs should include isometric and isotonic strengthening of the muscles surrounding the large joints, and maintenance of joint range of movement. If avascular necrosis is present, only isometric exercise is indicated. Aerobic training during active SLE flare can increase symptoms, aerobics should be avoided also if the hemoglobin is less than 11, Neurological complications will require appropriate program’s depending on the presentation.






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4.7 RESPIRATION:

4.7.1 ASTHMA: Asthma is a common problem for infants and children. It is also called ‘Reactive Airway Disease’. People

with asthma have sensitive airways, which become inflamed and swollen and produce more mucus. The muscles surrounding the airways (bronchial tubes) contract more than they should, narrowing the air passages (bronchoconstriction).

A. COMMON SYMPTOMS OF ASTHMA INCLUDE: Recurrent episodes of coughing Wheezing Difficulty breathing Shortness of breath Rapid and/or noisy breathing

Asthma symptoms tend to worsen at night or after with exposure to certain triggers, such as smoke, dust, pet hairs, weather changes, exercise, and colds and flu.

Whilst there is no cure for asthma, with the right management, most children's asthma can be kept under control. They will be able to participate in physical activities and sports and keep up with the other children. Many health authorities have dedicated asthma clinics, where your child can see a doctor, nurse and physiotherapist regularly for check-ups and to offer advice on keeping your child’s asthma under control.

B. PHYSIOTHERAPY ASSESSMENT:

I. YOUR CHILD’S MEDICATION: If they are taking a bronchodilator or steroid inhaler, your physiotherapist will check your

child’s technique to ensure they are getting the most from their medication. The triggers that set off your child’s asthma and ways of avoiding or minimizing them . We

will advise you and your child on how to keep a daily symptom diary, if you need help with identifying these triggers.

Your child’s peak flow rate . Your physiotherapist will help you to understand how, with older children, it can help predict and prevent an asthma attack. Keeping a peak flow diary will also help your child’s doctor determine if your child's asthma is under control. The warning signs for when your child is likely to have an asthma attack. These warning signs

include a drop in peak flows, worsening allergies, runny nose, cough and exposure to a known






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trigger. Keeping a daily symptom diary can be helpful in identifying warning signs of an asthma attack.

Your child’s exercise tolerance. We will advise you and your child on any specific exercises or activities to help build up strength and offer general advice on sports.

Your child’s breathing technique and their ability to clear secretions. Your physiotherapist will advise on breathing games for younger children and specific breathing techniques for older children. These may include the active cycle of breathing technique and autogenic drainage.

PT’s will discuss what to do if your child has an asthma attack, including breathing control, relaxation, and positions that can help during an attack.

C. TREATMENT TECHNIQUES FOR AN ASTHMA ATTACK:

I. TURNING: Turning from side to side permits lung expansion. Patients may turn themselves or be turned by a caregiver. The head of the bed is also elevated to promote drainage if the patient can tolerate this position. Critically ill patients and those dependent on mechanical respiration are turned once every one to two hours around the clock.

II. COUGHING:

Coughing helps break up secretions in the lungs so that the mucus can be suctioned out or expectorated. Patients sit upright and inhale deeply through the nose. They then exhale in short puffs or coughs. Coughing is repeated several times a day.

III. DEEP BREATHING:

Deep breathing helps expand the lungs and forces better distribution of the air into all sections of the lung. The patient either sits in a chair or sits upright in bed and inhales, pushing the abdomen out to force maximum amounts of air into the lung. The abdomen is then contracted, and the patient exhales. Deep breathing exercises are done several times each day for short periods.

IV. POSTURAL DRAINAGE:

Postural drainage uses the force of gravity to assist in effectively draining secretions from the lungs and into the central airway where they can either be coughed up or suctioned out. The patient is placed in a head or chest down position and is kept in this position for up to 15 minutes. Critical care patients and those depending on mechanical ventilation receive postural drainage therapy four to six times daily. Percussion and vibration may be performed in conjunction with postural drainage.

V. PERCUSSION:

Percussion is rhythmically striking the chest wall with cupped hands. It is also called cupping, clapping, or tapotement. The purpose of percussion is to break up thick secretions in the lungs so that they can be more easily removed. Percussion is performed on each lung segment for one to two minutes at a time.

VI. VIBRATION:

As with percussion, the purpose of vibration is to help break up lung secretions. Vibration can be either mechanical or manual. It is performed as the patient breathes deeply. When done manually, the person performing the vibration places his or her hands against the patient's






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chest and creates vibrations by quickly contracting and relaxing arm and shoulder muscles while the patient exhales. The procedure is repeated several times each day for about five exhalations.

VII. PREPARATION:

The only preparation needed for chest physical therapy is an evaluation of the patient's condition and determination of which chest physical therapy techniques would be most beneficial.

VIII. AFTERCARE:

Patients practice oral hygiene procedures to lessen the bad taste or odor of the secretions they spit out.

IX. RISKS:

Risks and complications associated with chest physical therapy depend on the health of the patient. Although chest physical therapy usually poses few problems, in some patients it may cause Oxygen deficiency if the head is kept lowered for drainage Increased intracranial pressure Temporary low blood pressure Bleeding in the lungs Pain or injury to the ribs, muscles, or spine Vomiting Inhaling secretions into the lungs Heart irregularities

X. NORMAL RESULTS:

The patient is considered to be responding positively to chest physical therapy if some, but not necessarily all, of these changes occur: Increased volume of sputum secretions Changes in breath sounds Improved vital signs Improved chest x ray Increased oxygen in the blood as measured by arterial blood gas values Patient reports of eased breathing Cardiopulmonary physiotherapists work with patients in a variety of settings. They treat acute problems like asthma, acute chest infections and trauma; they are involved in the preparation and recovery of patients from major surgery; they also treat a wide range of chronic cardiac and respiratory conditions like Chronic Obstructive Pulmonary Disease (COPD), cystic fibrosis (CF) and post-myocardial infarction (MI). They work with all ages from premature babies to older adults at the end of their life. Physiotherapists are pioneering new management techniques for non-organic respiratory problems like hyperventilation and other stress-related disorders as well as leading the development of cardio-pulmonary rehabilitation and non-invasive ventilation.






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4.7.2 CYSTIC FIBROSIS: Cystic Fibrosis (CF) is a condition where the glands in the body produce abnormally thick, sticky

mucus and the sweat glands produce excess salt. The two main areas of the body involved are the lungs and the pancreas. This increased production of mucus causes most of the problems seen in cystic fibrosis.

The lung problems of cystic fibrosis are caused by the thick sticky mucus, which makes them susceptible to infection and damage. The thick mucus collects in the lungs blocking some airways and resulting in damage caused by the infection. Much of this damage can be prevented through adequate treatment of infections. Physiotherapy and medication help to keep the lungs clear of the mucus.






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A. POSTURAL DRAINAGE AND CPT: Chest physical therapy is the term for a group of treatments designed to improve respiratory

efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.

I. PURPOSE:

The purpose of chest physical therapy, also called chest physiotherapy, is to help patients breathe more freely and to get more oxygen into the body. Chest physical therapy includes postural drainage, chest percussion, chest vibration, turning, deep breathing exercises, and coughing. It is usually done in conjunction with other treatments to rid the airways of secretions. These other treatments include suctioning, nebulizer treatments, and the administration of expectorant drugs.

Chest physical therapy can be used with newborns, infants, children, and adults. People who benefit from chest physical therapy exhibit a wide range of problems that make it difficult to clear secretions from their lungs. Some people who may receive chest physical therapy include people with cystic fibrosis or neuromuscular diseases like Guillain-Barré syndrome, progressive muscle weakness (myasthenia gravis), or tetanus. People with lung diseases such as bronchitis, pneumonia, or chronic obstructive pulmonary disease (COPD) also benefit from chest physical therapy. People who are likely to aspirate their mucous secretions because of diseases such as cerebral palsy or muscular dystrophy also receive chest physical therapy, as do some people who are bedridden, confined to a wheelchair, or who cannot breathe deeply because of postoperative pain.






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II. CHEST PHYSICAL THERAPY POSITIONS FOR INFANTS AND CHILDREN: Below are the drainage positions for CPT. The white ovals show you where to percuss.

During therapy it is useful to have tissue or a basin handy to collect mucus. A glass of water may also be helpful for those who can cough better after their throat is wet.

1. UPPER LOBES:

a. Lean forward 30°. Percuss between the clavicle and the shoulder blade on each side of the chest. Figure 1.

b. Lean back 30°. Percuss between the clavicle and the nipple on each side of the chest. (Figure 2)

2. LOWER LOBES: The body should be positioned with the child’s head down 30°and lying on the right

side. Percuss on the left side below the underarm. Note: If your child has Cystic Fibrosis and is under the age of 5, you will not be tilting the chest area, but will keep the chest horizontal.( Figure 3)

The body should be positioned with the child’s head down 30°and lying on the left side. Percuss on the right side below the underarm. Note: If your child has Cystic Fibrosis and is under the age of 5, you will not be tilting the chest area, but will keep the chest horizontal. (Figure 4)

The body should be positioned with the child’s head down 30°and lying on the abdomen. Percuss between the lower edges of the rib cage and behind the underarm on each side of the spinal cord. Note: If your child has Cystic Fibrosis and is under the age of 5, you will not be tilting the chest area, but will keep the chest horizontal. (Figure 5)

The body should be positioned with the child’s head down 30°and lying on the back. Percuss on the front of the chest in the nipple area and just below. Note: If your child has Cystic Fibrosis and is under the age of 5, you will not be tilting the chest area, but will keep the chest horizontal. (Figure 6)

.

The information provided should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call emergency for all medical emergencies. Any duplication or distribution of the information contained herein is strictly prohibited.






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III. PRECAUTIONS: Chest physical therapy should not be performed on people with Lungs Asthma attack Injuries Embolism Ribs Abscess Walls Hemorrhage Tuberculosis Injuries burns

IV. DESCRIPTION:

Chest physical therapy can be performed in a variety of settings including critical care units, hospitals, nursing homes, outpatient clinics, and at the patient's home. Depending on the circumstances, chest physical therapy may be performed by anyone from a respiratory care therapist to a trained member of the patient's family. Different patient conditions warrant different levels of training.

Chest physical therapy consists of a variety of procedures that are applied depending on the patient's health and condition. Hospitalized patients are reevaluated frequently to establish which procedures are most effective and best tolerated. Patients receiving long-term chest physical therapy are reevaluated about every three months.

V. TURNING:

Turning from side to side permits lung expansion. Patients may turn themselves or be turned by a caregiver. The head of the bed is also elevated to promote drainage if the patient can tolerate this position. Critically ill patients and those dependent on mechanical respiration are turned once every one to two hours around the clock.

VI. COUGHING:

Coughing helps break up secretions in the lungs so that the mucus can be suctioned out or expectorated. Patients sit upright and inhale deeply through the nose. They then exhale in short puffs or coughs. Coughing is repeated several times a day.

VII. DEEP BREATHING:

Deep breathing helps expand the lungs and forces better distribution of the air into all sections of the lung. The patient either sits in a chair or sits upright in bed and inhales, pushing the abdomen out to force maximum amounts of air into the lung. The abdomen is then contracted, and the patient exhales. Deep breathing exercises are done several times each day for short periods.

VIII. POSTURAL DRAINAGE:

Postural drainage uses the force of gravity to assist in effectively draining secretions from the lungs and into the central airway where they can either be coughed up or suctioned out. The patient is placed in a head or chest down position and is kept in this position for up to 15 minutes. Critical care patients and those depending on mechanical ventilation receive postural drainage therapy four to six times daily. Percussion and vibration may be performed in conjunction with postural drainage.

Percussio






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IX. PERCUSSION: Percussion is rhythmically striking the chest wall with cupped hands. It is also called

cupping, clapping, or tapotement. The purpose of percussion is to break up thick secretions in the lungs so that they can be more easily removed. Percussion is performed on each lung segment for one to two minutes at a time.

X. VIBRATION:

As with percussion, the purpose of vibration is to help break up lung secretions. Vibration can be either mechanical or manual. It is performed as the patient breathes deeply. When done manually, the person performing the vibration places his or her hands against the patient's chest and creates vibrations by quickly contracting and relaxing arm and shoulder muscles while the patient exhales. The procedure is repeated several times each day for about five exhalations.

XI. PREPARATION:

The only preparation needed for chest physical therapy is an evaluation of the patient's condition and determination of which chest physical therapy techniques would be most beneficial.

XII. AFTERCARE:

Patients practice oral hygiene procedures to lessen the bad taste or odor of the secretions they spit out.

XIII. RISKS:

Risks and complications associated with chest physical therapy depend on the health of the patient. Although chest physical therapy usually poses few problems, in some patients it may cause

Drainage Spine

Pressure Vomiting

lungs Irregularities

XIV.NORMAL RESULTS: The patient is considered to be responding positively to chest physical therapy if some, but

not necessarily all, of these changes occur: Increased volume of sputum secretions Improved chest x ray

Changes in breath sounds

Improved vital signs Patient reports of eased breathing

Vibration






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4.8 PEDIATRIC PHYSIOTHERAPY: Pediatric physical therapy assists in early detection of health problems and uses a wide variety of modalities

to treat disorders in the pediatric population. Children are not just miniature adults. Throughout development from babies to teenagers, children are

constantly growing and developing, physically, and psychologically. Only a highly experienced clinician is sufficiently qualified to care competently and compassionately for children.

Pediatric Physiotherapists are specialized in the diagnosis, treatment, and management of infants, children, and adolescents with a variety of congenital, developmental, neuromuscular, skeletal, or acquired disorders/diseases.

Treatments focus on improving gross and fine motor skills, balance and coordination, strength and endurance as well as cognitive and sensory processing/integration. Children with developmental delays, cerebral palsy, spina bifida, and Torticollis are a few of the patients treated by pediatric physiotherapists.

Pediatric Physiotherapists provide treatment for children who have delayed gross motor skills and/or lack flexibility, strength or endurance. Physical therapy program is on a one-on-one basis with a licensed physiotherapist. Each session is individualized to meet both the child and parent’s needs. Treatments may include exercises and or therapeutic activities that are specifically geared toward improving strength, balance, coordination, and endurance. Therapy goals are established with the parents to focus on helping children improve their function, mobility, relieve pain and prevent or limit permanent physical disabilities.

Therapists teach parents and children to use adaptive equipment, such as crutches, walkers and wheelchairs and also evaluate and make recommendations for orthotics.

Filename: PTP&M008 PTM of Oncology and Palliative Care-related Medical Journal

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Title: PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS

Subject: Author: Abdulrehman Mulla Keywords: Comments: Creation Date: 4/7/2009 10:15 PM Change Number: 122 Last Saved On: 6/7/2009 8:20 PM Last Saved By: Abdulrehman S. Mulla Total Editing Time: 8,881 Minutes Last Printed On: 6/7/2009 8:38 PM As of Last Complete Printing Number of Pages: 47 Number of Words: 11,152 (approx.) Number of Characters: 63,568 (approx.)

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