Peds: Torticollis, Juvenile Idiopathic Arthritis, Arthrogryposis Multiplex Congenita (AMC), Pelvic floor

Unilateral shortening/tightness of the SCM causing an asymmetrical head position

Congenita Muscular Torticollis (CMT)

SCM shortening

1. Lateral flexion on the same side

2. Rotate to the opposite direction

In a 6-month-old child demonstrating muscle contracture consistent with Left torticollis, what is the BEST stretching technique to normalize muscle length of thesternocleidomastoid?

Stabilize the left shoulder and stretch the neck into right side-bending and Left rotation

Classification for cranial deformation

Deformational plagiocephaly

Deformational Brachycephaly

Deformational Dolichocephaly

What is deformational plagiocephaly (DP)?

Ipsilateral occipital flattening

What is deformational brachycephaly (DB)?

Central occipital flattening associated with prolonged supine positioning

What is deformational dolichocephaly (DD)?

A disproportionately long and narrow skull, commonly associated with prematurity

Classification for CMT: 3 types

Postural CMT

Muscular CMT

Most severe form involving an SCM nodule/fibrous band

What characterizes postural CMT?

Mildest form; positional preference without PROM limitation or an SCM nodule

What characterizes muscular CMT?

Unilateral SCM tightness during lateral flexion and/or rotation without an SCM nodule

What characterizes the most severe CMT classification?

Palpable SCM nodule/fibrous bands with limited cervical rotation and/or lateral flexion

Grade 1 CMT Early Mild

0-6 months + only postural preference OR <15° difference in passive cervical rotation

Grade 2 CMT Early moderate

0-6 months + 15-30° difference in passive cervical rotation

Grade 3 CMT Early severe

0-6 months + >30° rotation difference OR an SCM mass

Grade 4 CMT Later mild

7-9 months + postural preference OR <15° rotation difference

Grade 5 CMT Later moderate

10-12 months + postural preference OR <15° rotation difference

Grade 6 CMT Later severe

7-9 months + >15° difference OR 10-12 months + 15-30° difference

Grade 7 CMT Later extreme

7-12 months + SCM mass OR 10-12 months + >30° rotation difference

Grade 8 CMT Very late

>12 months with any asymmetry: postural preference, ROM difference, or SCM mass

What UE functional limitations may occur on the involved side?

Difficulty with UE weight bearing and reaching toward midline

What other musculoskeletal asymmetries can occur with CMT?

Trunk curvature toward the affected SCM and persistence of the asymmetric tonic neck reflex

Cervical strength: Muscle function test Scale

0 = with the head below horizontal,

1 = with the head on the horizontal line,

2 = with the head slightly over the horizontal line,

3 = with the head high over the horizontal line

4 = with the head very high over the line approaching vertical

What are the major PT interventions for CMT?

Positioning, stretching, parent education, active/passive ROM, strengthening, and symmetrical movement activities

Recommended Interventions for Cranial Deformation: Brachycephaly

Inc prone positioning to relieve pressure on occiput to allow for reshaping

Recommended Interventions for Cranial Deformation: Plagiocephaly

Head turning and positioning opposite of preferred position, inc time in prone, facilitation of development to encourage overall movement away from flattened side

What is the first-choice intervention for CMT with strong evidence?

Caregiver education, environmental adaptations, PROM, neck/trunk AROM, and symmetrical movement activities

What are the main conservative interventions for cranial deformation under 6 months?

Parent/caregiver instruction in and adherence with repositioning, inc supervised prone play while awake, environmental adaptations, Cranial remolding therapy is indicated for infants with moderate to severe CD at 3-6 months of age or older

How long are cranial orthoses typically worn per day?

20-23.5 hours/day

How long may cranial remolding therapy last?

2-7 months for optimal outcomes

What is the CMT stretch for a left tight SCM?

R tilt and L rotation

What is the CMT stretch for a right tight SCM?

L lateral flexion with R rotation

What is the general stretching frequency for 1-person passive stretching?

2-3 times/day, 5-15 repetitions, with 1-10-second holds

What is the general frequency for 2-person passive stretching?

4-8 times/day, with at least 30-40 repetitions per set

If CMT is not resolving after 4-6 weeks of therapy

referral back to the physician be considered

What are indications for surgical management of CMT?

No improvement after 6 months

Residual head tilt

≥15° PROM deficit

Tight muscular band

When is surgery most likely to have a positive outcome?

Between 10 months and 5 years of age

Face Legs, Activity, Cry, and Consolability scale (FLACC)

Used to assess pain in infants, young children

What is the FLACC score range?

0-10

FLACC — Face = 0

No particular expression or smile.

FLACC — Face = 1

Occasional grimace or frown, withdrawn, disinterested

FLACC — Face = 2

Frequent to consistent quivering chin, clenched jaw

FLACC — Legs = 0

Normal position or relaxed

FLACC — Legs = 1

Uneasy, restless, tense

FLACC — Legs = 2

Kicking or legs drawn up

FLACC — Activity = 0

Lying quietly, normal position, moves easily

FLACC — Activity = 1

Squirming, shifting back and forth, tense

FLACC — Activity = 2

Arched, rigid, or jerking

FLACC — Cry = 0

No cry (awake or asleep)

FLACC — Cry = 1

Moans or whimpers; occasional complaint

FLACC — Cry = 2

Crying steadily, screams, or sobs; frequent complaints

FLACC — Consolability = 0

Content, relaxed

FLACC — Consolability = 1

Reassured by occasional touching, hugging, or being talked to

FLACC — Consolability = 2

Difficult to console or comfort

An autoimmune inflammatory disorder in which the body mistakenly identifies some of its own cells/tissues as foreign. It is the most common rheumatic disease of childhood

Juvenile Idiopathic Arthritis (JIA)

What are the diagnostic characteristics of JIA?

Begins before age 16

Persists for >6 weeks

Cause is unclear

No definitive laboratory test

Diagnosis is primarily based on clinical signs/symptoms during the first 6 months

What are the 3 most common types of JIA?

1. Oligoarticular (pauciarticular)

2. Polyarticular

3. Systemic

What are common signs/symptoms of JIA?

Inflammation causing redness, heat, pain, and swelling

What long-term problems can JIA cause?

Chronic joint swelling

Pain

Limited ROM

Muscle atrophy/weakness

Poor aerobic function

Impaired exercise tolerance

Postural abnormalities

Gait deviations

Activity/participation restrictions

Reduced QOL

What is the most common type of JIA?

Oligoarticular (pauciarticular) JIA

How many joints are affected in oligoarticular JIA?

Four or fewer joints, with low-grade inflammation

Who is commonly affected by oligoarticular JIA?

Girls 2-4 years

Which joints are most commonly affected in oligoarticular JIA?

Knee, ankle, elbow

What is an important eye complication of oligoarticular JIA?

Iridocyclitis, an inflammation of the iris and ciliary body

Arthritis involving 5 or more joints

Polyarticular JIA

How is polyarticular JIA subdivided?

Into rheumatoid factor (RF)-positive and RF-negative polyarthritis

What functional problem can severe polyarticular JIA cause in the hands?

Difficulty fully extending the fingers due to joint involvement/contractures

What is the hallmark diagnostic feature of systemic JIA?

Spiking fever ≥39°C (102.2°F) occurring once or twice daily, typically in the afternoon/evening, for at least 2 weeks accompanied by a rash

What are the major goals of PT intervention for JIA?

Maintain/preserve joint function

Restore or compensate for function/activity

Manage pain

Prevent deformity

Maintain/improve ROM

Strengthen

Improve proprioception

Protect joints

Promote functional abilities

Improve physical fitness

What is the treatment for a 0-2 cm leg length inequality?

No treatment

What is the treatment for a 2-4 cm leg length inequality?

Shoe lift

What is the treatment for a 2-6 cm leg length inequality?

Epiphysiodesis or shortening

What is the treatment for a 6-20 cm leg length inequality?

Lengthening, possibly combined with other procedures

What is the treatment for a leg length inequality >20 cm?

Prosthetic fitting

Therapy intervention for the acute phase

Child and family education

Pain management, deformity prevention

ROM maintenance or improvement, strengthening, proprioceptive training

Joint protection strategies

Promotion of functional abilities

Physical fitness

What intervention is used for morning stiffness in JIA?

Movements of any kind, especially movement in the extension direction of joints and stretching of biarticular muscles

What intervention is used to improve joint ROM in JIA?

Gentle movements of any kind, especially movements in the extension direction of joints and stretching of biarticular muscles

What intervention is used for decreased muscle strength in JIA?

Isometric and isokinetic muscle-strengthening exercises

What intervention is used to improve health-related physical fitness in JIA?

Aerobic

What interventions can be used for pain behaviors in JIA?

Relaxation with mindfulness, tai chi, or qigong

What intervention can be used to address gait problems in JIA?

Insoles (soft or supinating, retrocapital support) or rocker-bottom external soles

T or F: Full extension is only restored when the intraarticular effusion ( joint swelling) has disappeared

T

An adolescent with polyarticular JIA is clinically stable with minimal morning stiffness. Which aerobic prescription is MOST appropriate?

A. 10 minutes of jump training at 85-90% HRmax, 6-7 days/week

B. 20-30 minutes of cycling or swimming at moderate intensity, 3-5 days/week

C. Isometric only; avoid all aerobic activity

D. Treadmill running to pain tolerance, 5 days/week

B. 20-30 minutes of cycling or swimming at moderate intensity, 3-5 days/week

A 10-year-old with known JIA develops daily spiking fevers, a salmon-colored rash, and reports chest pain with shortness of breath during your session. What is the BEST action?

A. Continue with low-intensity cycling and monitor symptoms

B. Stop therapy and arrange urgent medical evaluation

C. Apply moist heat and begin diaphragmatic breathing

D. Instruct home rest and recheck next visit

B. Stop therapy and arrange urgent medical evaluation

A 7-year-old with known juvenile idiopathic arthritis has a medically confirmed flare affecting the right knee. The knee is warm and swollen, with pain at end-range motion. Which PT intervention is MOST appropriate during this session?

A. High-load isotonic quadriceps training and aggressive stretch

B. Prolonged immobilization in a knee immobilizer during the day

C. Pain-free AROM, cold application post-session, and a night extension splint

D. Continuous ultrasound (1.5 W/cm²) over the distal femoral physis

C. Pain-free AROM, cold application post-session, and a night extension splint

A child is newly diagnosed with juvenile idiopathic arthritis and reports no eye symptoms. Which screening referral should be arranged early?

A. Echocardiogram for cardiomyopathy

B. Slit-lamp eye exam by ophthalmology

C. DEXA scan for low bone density

D. EMG for peripheral neuropathy

B. Slit-lamp eye exam by ophthalmology

A 4-year-old girl has a painless swollen left knee and intermittent ankle swelling for 3 months. Which JIA subtype is MOST likely?

A. Systemic JIA

B. Enthesitis-related JIA

C. Oligoarticular (pauciarticular) JIA

D. Polyarticular JIA

C. Oligoarticular (pauciarticular) JIA

A congenital, nonprogressive neuromuscular disorder characterized by joint contractures in 2 or more body areas, often associated with muscle weakness

Arthrogryposis Multiplex Congenita (AMC)

Clinical signs of AMC

Severe joint contractures and lack of muscle development

Limit participation in even basic ADLs

What are common musculoskeletal findings in AMC?

Hip flexion/dislocation

Knee contractures

Clubfeet/equinovarus

Internally rotated shoulders

Flexed elbows

Flexed/ulnar-deviated wrists

Muscle hypoplasia/weakness

What are the major components of early PT management for AMC?

Vigorous stretching

Splinting

Positioning

Strengthening

Developing optimal positions for ADLs and motor skill development

Which finding is MOST consistent with AMC?

A. Hyperreflexia and velocity-dependent tone

B. Multiple rigid joint contractures with muscle hypoplasia and normal cognition

C. Fluctuating weakness with fatigability worsened by activity

D. Recurrent joint effusions and warmth

B. Multiple rigid joint contractures with muscle hypoplasia and normal cognition

A group of genetic disorders causing fragile bones, usually due to problems with type I collagen

Osteogenesis Imperfecta (OI)

What is a classic ocular finding in OI?

Blue-gray or blue sclerae

What other features may occur with OI?

Short stature, bone deformity, joint laxity, and hearing loss

OI Type I

Mildest form

Few to multiple fractures, little bone deformity, blue/gray sclerae, and near-normal height/life expectancy

When do Type I fractures often decrease?

After puberty

OI Type II

Most severe

Extremely fragile bones, bowed/crumpled long bones, poor chest development, and pulmonary insufficiency

Why do many infants with OI Type II die early?

Respiratory failure related to underdeveloped lungs

OI Type III

Severe progressive deformity, frequent fractures, short stature, and substantial mobility limitations

What may contribute to breathing problems in OI Type III?

Spinal and chest wall deformities