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Monday October 17, 2011


While many PTs associate manual physical therapy with musculoskeletal complaints in adults, pediatric specialists are discovering these techniques also are effective in children, and can reduce pain, decrease swelling, improve movement and restore the body’s ability to function optimally.

Getting hands-on

Manual therapy techniques are emphasized at one or multiple targeted tissues: the joint, nerve or soft tissue. PTs use their hands to put pressure on muscle tissue and manipulate joints in an attempt to decrease back pain caused by muscle spasm, muscle tension and joint dysfunction. Manual techniques can include soft tissue mobilization, strain-counterstrain, joint mobilization, muscle energy and nonthrust manipulation.

“PTs need to view manual therapy as another adjunct treatment,” said Kenneth Learman, PT, PhD, OCS, COMT, FAAOMPT, associate professor in the department of physical therapy at Youngstown (Ohio) State University. “Some indications have shown that manual therapy can help with mechanical joint dysfunction in which there is restriction of joint play leading to pain or limitation of active physiological movement.”

Learman is joining Megan Donaldson, PT, PhD, FAAOMPT, assistant professor of physical therapy at the Walsh University DPT program in Canton, Ohio, to present at the American Academy of Orthopaedic Manual Physical Therapists annual conference scheduled for Oct. 26-30 in Anaheim, Calif.

“Manual therapy is recommended for pediatric patients with juvenile rheumatoid arthritis to control pain and prevent limitation, as well as increasing endurance for activities of daily living and minimizing effects of inflammation,” Donaldson said. “Many disciplines are treating children for orthopedic conditions with different manual approaches.”

Darlene Hertling, a PT in Lake Forest Park, Wash., and the author of several books, including “Manual Therapy for Functional Mobility: A Neuromuscular Approach,” used manual therapy techniques for many years in her work with children at the Boyer Children’s Clinic in Seattle before opening a private practice.

“Many PTs use the Bobath treatment that aims to improve posture and movement to enable children with cerebral palsy [to have] more realistic functioning in daily life,” Hertling said. “Yet the Bobath treatment and manual therapy can be actually used together and serve to complement each other.”

Manual therapy also can be helpful in young children who have muscle tone that is too high, causing stiff muscles and tight joints, Hertling said.

“Gentle methods, including stretching, mobilization and other hands-on approaches can encourage improved movements in pediatric patients,” Hertling said. “I have also recommended yoga as an adjunct to integrated manual therapy.”

More studies needed

Learman said the current dilemma for PTs is that while there is an abundance of research available on how manual therapy can benefit adults, there is limited evidence available on how it benefits pediatric patients.

“We definitely need more studies on how manual therapy can benefit children. Current literature has limited support for the use of sustained stretching and manual passive stretching for conditions associated with contractures and neuromuscular disorders,” he said.

Learman encouraged PTs to work with academic institutions if they have ideas for relevant studies. “It’s wonderful when clinicians can become data collectors and help spearhead research projects by suggesting an area that interests them and then helping to obtain relevant data from their patients,” he said.

Donaldson said while there is no current legislation preventing chiropractors and others from performing manipulation on infants, this has been the group of highest risk and injury reports. “Physical therapists should not advocate to perform manipulation on the infant with torticollis, when non-thrust techniques are just as effective and with less risk to the patient with an immature skeletal and nervous system,” she said.

Donaldson added that many techniques, including muscle energy also could be used to benefit more pediatric patients, especially older children and teens who have decreased range of motion secondary to muscular spasticity, rigidity, hypertonicity or hypotonicity. “Muscle energy can help with the mobilization of restricted joints and strengthen weakened muscles,” she said.

Mobilization is another area that tends to be underused with pediatric patients, Learman said. Soft tissue mobilization can break up excess scar tissue and adhesions that weaken a child’s muscles and contribute to further injury. Rib cage mobilization or massage to the respiratory mechanism can increase sound production, volume and physical endurance.

“Joint mobilization is a passive technique designed to restore normal range of motion in affected joints and can work with PTs who treat young athletes with sports injuries,” Learman said. “By gently moving motion-restricted joints through a specific part of the range, joint receptors can be re-educated to allow a greater pain-free range of motion.”

Special considerations

Because pediatric PTs work with a wide range of patients from infancy to age 18, Donaldson said it’s important to assess each individual by looking at patient size, developing bones or growth plates, and flexibility of joints to determine whether he or she is a good candidate for manual therapy.

“Growth and change happen quickly during the pediatric years,” Donaldson said. “Use manipulation and soft tissue techniques and procedures that support the needs and comfort of the pediatric patient.”

Age-appropriate communication is key to keeping a young patient actively involved in the treatment, and it’s important for PTs to secure informed consent from a patient’s parents before beginning manual therapy, Donaldson said. “Anyone practicing manual therapy needs to have a conversation with the parents to ensure they fully understand the treatment,” she said. “Parents need to be aware of any risks and complications.

Linda Childers is a freelance writer.

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Monday October 17, 2011
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