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📚 PEDIATRIC PHYSIOTHERAPY — BPT EXAM NOTES

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UNIT 1: GROWTH & DEVELOPMENT

1.1 Terminology

• Growth — increase in physical size (quantitative)
• Development — acquisition of skills/function (qualitative)
• Maturation — biological progression toward adult form
• Differentiation — cells/tissues becoming specialized

1.2 Principles of Development

1. Cephalocaudal (head → tail)
2. Proximodistal (trunk → limbs)
3. Mass to specific (gross → fine)
4. Sequential and orderly
5. Rate varies but sequence is constant

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UNIT 2: DEVELOPMENTAL MILESTONES

2.1 Motor Milestones (Movement/Physical)

2.2 Language Milestones

2.3 Social/Emotional Milestones

2.4 Developmental Red Flags (Alarm Signs)

• No social smile by 3 months
• Not rolling by 6 months
• Not sitting by 9 months
• Not walking by 18 months
• Not using 2-word phrases by 2 years
• Loss of previously acquired skills at any age → immediate evaluation

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UNIT 3: PEDIATRIC ASSESSMENT

3.1 General Principles

• Observe before touching
• Use age-appropriate communication
• Include parents in history
• Developmental surveillance at every well-child visit
• Formal screening at 9, 18, and 30 months (AAP guidelines)

3.2 Common Screening Tools

3.3 Reflex Assessment

Exam tip: Persistence of primitive reflexes beyond their expected disappearance = sign of CNS dysfunction (especially cerebral palsy).

3.4 Postural Reactions (should appear and persist)

• Righting reactions — maintain head/body alignment
• Equilibrium reactions — restore balance when displaced
• Protective reactions (parachute) — arm extension to prevent falling

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UNIT 4: CEREBRAL PALSY (CP)

4.1 Definition

• Non-progressive brain injury → but clinical features may change with growth
• Goldman-Cecil Medicine: "Permanent disorders of movement and posture… often follows perinatal insult (asphyxia, intrauterine infection, hemorrhage, prematurity, or brain infarction)"

4.2 Causes / Risk Factors

~20% of cases are idiopathic; ~1/3 of idiopathic cases have de novo copy number variants.

4.3 Classification

By Tone / Movement Disorder:

By Topography:

4.4 Clinical Features

• Delayed motor milestones
• Abnormal tone (hyper or hypo)
• Persistence of primitive reflexes
• Absence of postural reactions
• Scissor gait (spastic diplegia)
• Hemiplegia gait (circumduction)
• Crouch gait
• Associated features: epilepsy (~30–50%), intellectual disability (~50%), visual problems, hearing loss, speech/language disorders, feeding difficulties

4.5 GMFCS (Gross Motor Function Classification System)

4.6 Physiotherapy Management of CP

A. Handling & Positioning

• Inhibitory handling (reflex inhibiting postures — RIP)
• Key points of control: head, shoulder girdle, pelvis
• Anti-spasticity positioning (e.g., avoid hip adduction/internal rotation)
• Equipment: standing frames, prone standers, adaptive seating

B. Therapeutic Approaches

• NDT (Neurodevelopmental Treatment / Bobath) — normalize tone, facilitate normal movement patterns
• Vojta Therapy — reflex locomotion to activate normal motor programs
• Conductive Education (Peto) — task-oriented learning
• Constraint-Induced Movement Therapy (CIMT) — for hemiplegia, constrain good limb to force use of affected limb
• Treadmill Training / Locomotor Training — gait re-education
• Hydrotherapy — buoyancy reduces spasticity, facilitates movement

C. Gait Analysis

• Used to plan management in ambulant children
• Identifies: excessive hip flexion, crouch gait, equinus, scissoring
• Informs botulinum toxin injections and surgical planning

D. Orthoses

• AFO (Ankle-Foot Orthosis) — most common; corrects equinus, improves gait
• KAFO — knee-ankle-foot orthosis
• TLSO — for scoliosis
• Hip abduction orthosis — prevent subluxation

E. Medical & Surgical Management (for context)

• Botulinum toxin A — reduces focal spasticity (most useful 2–6 years)
• Oral baclofen — systemic spasticity
• Intrathecal baclofen (ITB) pump — severe spasticity/dystonia
• Selective Dorsal Rhizotomy (SDR) — reduces spasticity permanently; PT intensive post-op
• Tendon lengthening / transfers — correct fixed deformities
• Hip surveillance — TBI children monitored for subluxation

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UNIT 5: SPINA BIFIDA / MYELOMENINGOCELE (MMC)

5.1 Definition & Types

Incidence 0.04–0.15%; more common in girls. Folic acid (400 mcg) before and during early pregnancy significantly reduces incidence.

5.2 Pathology

• Failure of neural tube closure during 3rd–4th week of embryonic development
• Results in flaccid paralysis, sensory loss, and autonomic dysfunction below the level of lesion
• Upper motor neuron signs if lesion involves higher cord (spasticity)
• Lower motor neuron lesion → flaccid paralysis (more common in MMC)

5.3 Associated Conditions

• Hydrocephalus (~80–90%); requires ventriculoperitoneal (VP) shunt
• Arnold-Chiari Malformation Type II — cerebellar/brainstem herniation
• Tethered cord syndrome — worsens with growth
• Neurogenic bladder & bowel
• Latex allergy (high risk — must use latex-free during all procedures)
• Pressure sores — due to sensory loss
• Secondary scoliosis, kyphosis

5.4 Level of Lesion & Functional Prognosis

5.5 Physiotherapy Management

• Pre-operative: positioning to protect sac
• Post-closure: handling, sensory stimulation, family education

• Passive ROM exercises — prevent contractures
• Strengthening available muscles
• Orthosis prescription (AFO, KAFO, HKAFO as per level)
• Standing program (parapodium, swivel walker)
• Functional mobility training
• Wheelchair skills if non-ambulatory

• Skin integrity — pressure relief, sensory impairment counseling
• Bladder — intermittent catheterization program (CIC)
• Scoliosis monitoring and management
• Tethered cord — watch for declining function, back pain
• VP shunt — watch for signs of blockage (headache, vomiting, drowsiness)

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UNIT 6: DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

6.1 Definition

• Distinct from teratologic dislocation (dislocated in utero, irreducible at birth)

6.2 Risk Factors (Remember: F-FLAB)

• Female sex (6:1 female predominance)
• Firstborn
• Left hip more common
• Abnormal presentation (breech)
• Breech position + Family history

6.3 Clinical Tests

Ortolani & Barlow are most sensitive in first 2–3 months. After 3 months, limited abduction is the key sign.

6.4 Imaging

• Ultrasound — gold standard in neonates (bones not yet ossified)
• X-ray — useful after 4–6 months (ossification begins)
  • Hilgenreiner line, Perkin line, Shenton line used for assessment
  • Acetabular index (normal < 30° at birth; < 20° by 2 years)

6.5 Treatment by Age

Complication: Avascular necrosis (AVN) of femoral head — risk with excessive abduction in Pavlik harness.

6.6 Physiotherapy Role

• Post-reduction hip mobilization
• Strengthening hip abductors (after cast removal)
• Gait re-education
• Parent education on harness/cast care
• Monitoring for AVN, re-dislocation

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UNIT 7: CONGENITAL TALIPES EQUINOVARUS (CTEV) / CLUBFOOT

7.1 Definition

• C — Cavus (high arch)
• A — Adductus (forefoot adduction)
• V — Varus (hindfoot varus)
• E — Equinus (plantarflexion)

7.2 Anatomy

• Talar neck deformity with medial and plantar deviation
• Medial rotation of calcaneus
• Medial displacement of navicular and cuboid
• Shortening/contraction of: intrinsic muscles, Achilles tendon, tibialis posterior, FHL, FDL, joint capsules, ligaments

7.3 Epidemiology

• Incidence: ~1 in 1,000 live births
• Boys affected 2x as often as girls
• 50% are bilateral
• Majority idiopathic (PITX1-TBX4 pathway)
• Associated with: arthrogryposis, myelomeningocele, diastrophic dwarfism, tibial hemimelia

7.4 Pirani Scoring (Assessment)

• Hindfoot score (3 signs): equinus, posterior skin crease, empty heel
• Midfoot score (3 signs): curved lateral border, medial skin crease, talar head coverage

7.5 Treatment

A. Ponseti Method (Gold Standard)

1. Cavus — correct first by supinating forefoot, dorsiflexing 1st ray
2. Adductus — lateral pressure on distal talar head
3. Varus — corrected with adductus
4. Equinus — last; 90% require percutaneous Achilles tenotomy

• Weekly serial long-leg plaster casts (usually 5–7 casts)
• Final cast in 70° abduction
• After casting: foot-abduction brace (FAB) — Dennis Browne splint
  • Full-time (23 hrs/day) for 3 months → then nighttime until age 4–5 years
• Non-compliance with brace = 89% relapse rate

B. French Physiotherapy Method (Functional Method)

• Daily manipulation + taping by physiotherapist
• Continuous passive mobilization
• Less common in resource-limited settings

C. Surgical (for resistant/neglected cases)

• Posteromedial release (PMR)
• Tendon transfers (tibialis anterior transfer)

7.6 Physiotherapy Role (Ponseti)

• Educate parents on home stretching after cast removal
• Ensure brace compliance (key role)
• Teach Achilles/calf stretching
• Strengthen tibialis anterior and peroneals
• Monitor for relapse (adduction of big toe = first sign of relapse)

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UNIT 8: SCOLIOSIS

8.1 Definition

• Lateral curvature (coronal)
• Rotation (transverse) — creates rib hump on forward bending (Adam's forward bend test)
• Kyphosis/lordosis changes (sagittal)

8.2 Classification

Idiopathic Scoliosis by Age of Onset:

8.3 Cobb Angle & Treatment Guidelines

Idiopathic scoliosis is generally not painful → pain = investigate for tumour or infection.

8.4 Clinical Assessment

• Adam's Forward Bend Test — patient bends forward 90°; observe for rib hump/lumbar prominence (use scoliometer > 7° for referral)
• Plumb line — check trunk balance
• Shoulder height, pelvic tilt, leg length discrepancy
• Risser sign on X-ray (skeletal maturity)

8.5 Bracing

• Milwaukee brace — cervical-thoracic-lumbar-sacral (CTLSO); thoracic curves
• Boston/TLSO brace — lumbar and thoracolumbar curves; most common
• Charleston brace — nighttime bend brace
• Worn 23 hours/day until skeletal maturity (Risser 5)

8.6 Physiotherapy Management

• SEAS (Scientific Exercise Approach to Scoliosis) — Italian method
• Schroth Method — breathing + 3D correction exercises (most evidence-based)
• Lyon Method — French method
• Goal: halt progression, improve posture, breathing

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UNIT 9: OTHER COMMON PEDIATRIC CONDITIONS

9.1 Muscular Dystrophy (Duchenne — DMD)

• X-linked recessive; affects boys; onset 3–5 years
• Gowers' sign (uses arms to climb up legs to stand) — proximal muscle weakness
• Calf pseudohypertrophy
• Progressive: wheelchair by age 10–12; respiratory failure by 20s
• Physiotherapy: stretching (Achilles, ITB, hip flexors), standing program, respiratory physiotherapy (IPPB, assisted cough), hydrotherapy, wheelchair management

9.2 Brachial Plexus Birth Palsy (BPBP / Erb's Palsy)

• Erb's palsy (C5-C6): "Waiter's tip" posture — shoulder adducted/IR, elbow extended, forearm pronated, wrist flexed
• Klumpke's (C8-T1): Hand/wrist involvement
• PT: PROM (prevent contractures), AROM facilitation, positioning, splinting, sensory stimulation
• Prognosis: most recover spontaneously by 3–6 months

9.3 Torticollis (Congenital Muscular Torticollis — CMT)

• Fibrosis/shortening of sternocleidomastoid (SCM) muscle
• Head tilts to affected side, chin rotates to opposite side
• Palpable sternomastoid tumor in infancy
• PT (Gold standard): SCM stretching — lateral flexion away from tight side, rotation toward tight side; 3x daily
• Splinting/orthosis if conservative fails; surgery (tenotomy) for refractory cases
• Treat before 1 year for best results

9.4 Legg-Calvé-Perthes Disease (LCPD)

• Avascular necrosis of the proximal femoral epiphysis
• Age 4–8 years; boys > girls (4:1); usually unilateral
• Presents with: groin/knee pain, limp, limited hip abduction & IR
• X-ray: fragmentation → reossification → remodeling (takes 2–5 years)
• PT: Pain management, maintain ROM (hip abduction exercises), traction, non-weight bearing initially, crutches; bracing (containment orthosis)

9.5 Juvenile Idiopathic Arthritis (JIA)

• Arthritis in < 16 years, lasting > 6 weeks
• PT: Joint protection, hydrotherapy, splinting (resting + functional), strengthening, maintain ROM, school reintegration

9.6 Down Syndrome (Trisomy 21)

• Hypotonia (hallmark), joint laxity, intellectual disability
• Atlantic axial instability — must screen before PT (avoid diving, somersaults)
• PT: Motor development facilitation, strengthening, positioning, sensory integration, school support

9.7 Autism Spectrum Disorder (ASD)

• Impaired social communication + repetitive behaviors
• ~50% have sensory processing difficulties
• PT role: Sensory integration therapy, gross motor skills, coordination, behavioral management integration, aquatic therapy

9.8 Pediatric Respiratory Physiotherapy

• Active Cycle of Breathing Technique (ACBT) — adults and older children
• Postural drainage — gravity-assisted secretion clearance
• Manual techniques: percussion, vibration, shaking
• Autogenic drainage — self-drainage technique
• High-frequency chest wall oscillation (HFCWO) — vest therapy
• Flutter/Acapella — oscillating PEP devices
• Incentive spirometry — post-operative
• Positioning — upright for asthma/bronchiolitis; prone for ARDS

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UNIT 10: ORTHOTIC DEVICES IN PEDIATRIC PT

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UNIT 11: GAIT ANALYSIS IN CHILDREN

Normal Gait Parameters

• Cadence: 170 steps/min (toddler) → 120 steps/min (adult)
• Mature gait pattern established by age 7 years
• Components: stance (60%) / swing (40%)

Abnormal Gait Patterns

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UNIT 12: KEY PHYSIOTHERAPY TREATMENT APPROACHES

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QUICK EXAM REVISION TABLE

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Sources: The Harriet Lane Handbook (23rd ed.); Bailey & Love's Surgery (28th ed.); Miller's Review of Orthopaedics (9th ed.); Schwartz's Principles of Surgery (11th ed.); Goldman-Cecil Medicine; Kaplan & Sadock's Synopsis of Psychiatry

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