Children with motor disorders will benefit from assessment, treatment and/or consultation with a pediatric physiotherapist. Pediatric physiotherapists are specialized in the treatment of children. They have an in–depth understanding of what is supposed to be the normal development of the child, as well as the child’s anatomy, physiology and neurological framework, which they are often called upon to apply to pediatrics. They are therefore able to recognize motor difficulties at a very early age (as early as two to four months).

The physiotherapists assess children regarding their range of motion, muscle strength, gross motor function and quality of movement. Difficulty in any of these areas may be a result of a motor disorder, and this in turn, hinders the child’s ability to explore his/her environment. The ultimate goal of therapy is the facilitation of optimal, functional movement. With movement, the child can explore his/her immediate environment more easily and learn by it. It is important that all children who have a movement disorder, or are at a risk to develop such difficulties be screened as early as possible by a pediatric physiotherapist. Although intervention is available at any age, the earlier this begins, the better it is for the child, as then the child could begin to achieve optimal, functional movement and overcome any difficulties he/she may be faced with.

Physiotherapy Before & After Heart Surgery
Chest physiotherapy is an important part of recovery following surgery. Children who have had chest surgery often need physiotherapy to help prevent and decrease lung problems. The anesthetic and the operation itself sometimes results in more secretions than usual in the lungs and after the surgery your child will be less active than normal.

Before the operation
A physiotherapist may see your child before the operation to teach techniques such as deep breathing exercises, huffing and effective coughing. If the child is old enough then an “Incentive spirometer” is used. If needed, the physiotherapist may treat the child to remove secretions before the operation.

After the operation
A physiotherapist will come and see your child the day after the operation. Whether your child is still on the breathing machine (ventilator) or breathing by himself/herself, the physiotherapist will be checking that the lungs are clear of secretions and using techniques such as chest percussion and vibrations to help clear them. Suction may be used to remove the extra secretions from the lungs if they are unable to cough.

A physiotherapist will continue to see your child until physiotherapy is no longer needed. This is usually three to five days. If physiotherapy is still required when it is time for you to go home, the physiotherapist will teach you how to do the techniques before you go.

Physiotherapy in Muscular Dystrophy
Definition
The healthy baby, as it grows through infancy into childhood, gradually acquires the movement skills and muscle strength that it needs to perform complex tasks. In some areas he/she develops at the same pace as other children e.g. in social skills and intellectual achievement. However, the child will be slower to achieve skilled movement and some movements may never be possible. But development is taking place so it is important to encourage and improve upon what your child can do.

It is usually quite difficult to say, with certainty, during the first eighteen months, to what extent your child will be able to stand or achieve limited walking using orthoses (callipers, braces). This is because the condition affects the normal physical ‘Milestones’ by which development can usually be judged. A general approach is to recognize that some ‘Milestones’, e.g. crawling, may be missing from your child’s repertoire but the important thing is to work on what your child can do at present.

Aims of Physiotherapy
1. To improve, delay or help prevent contractures:
A contracture happens when weak muscles are unable to move a joint through its full range. This leads to tightness in the muscle itself and structures around the joint. Contractures occur in places where the muscles that bend the joint are stronger than the ones that straighten it e.g. in the ankles, hips, elbows and knees.
Contractures may:

• Make standing more difficult.
• Be uncomfortable and make management difficult.
• Affect spinal posture.
• Further disadvantage the weaker muscles.

2. To try and improve muscle strength and assist movement
Muscles become stronger with activity, ideally through working against resistance however small that may be. Exercises are the best way of gaining some improvement in muscle strength and your child will be able to exercise if you organize his/her play in a certain way. If parents know the aims of exercise, they can become very good at structuring the play to stimulate movement.

Exercises
When a young child is very weak, playing with him/her to encourage a physical muscle response can be part of the fun you will enjoy having with your baby. When he/she cannot make a movement you can show how to do it by moving the limbs or the trunk yourself in the desired direction and encourage your child to help you. The more a muscle is used, the stronger it becomes, although of course, this does not make the disorder go away. What does happen is that the remaining muscle fibers which are not affected can be encouraged to work and can be strengthened in partial compensation for the weakness of others. This type of active exercise and practice of movements is going to be important throughout your child’s life.

Passive Stretching
Passive stretching is where you are doing all the work. Ideally it is performed daily to all necessary joints through a full range. Use a firm surface such as a mat on the floor. It is also useful to do the exercises at the same time every day. Physiotherapy should start as soon as the child has been diagnosed, even with a very young baby.

Hips
The hip joint is controlled by some of the largest muscles in the body. The two groups that are most likely to become contracted are those that control the bending or forward lifting of the leg (the hip flexors) and those that move the leg out to the side (the hip abductors). There are three different ways in which these muscles can be stretched. When possible, all hip exercises should be repeated about 10 times on each side.

A. The child lies on one side with the top leg straight (the hip to be stretched) and the helper positioned behind. The bottom leg may be bent or straight. Place one hand firmly on top of the hip bone to steady it and slide the other hand under the thigh of the top leg, just above the knee. The leg is then drawn backwards towards you to stretch the hip flexors which lie across the front of the hip joint.

If you choose this method you must be sure that the pelvis is steady. You can put your knee against the child’s lower back so that your thigh acts as a cushion. Repeat the stretch on the other side.

B. The child lies face down. One hand is placed firmly on the buttocks on the same side as the hip to be stretched and the other hand is slipped under the thigh just above the knee. The thigh is then lifted and thus extended, stretching the front muscles of the hip and thigh. Repeat with the other leg.

C. The child lies on his/her back and the opposite leg (the one not being stretched) is bent up towards the chest and held in that position by you or the child, if he/she can manage it. Your hand is then placed just above the knee of the leg to be stretched and a downward pressure is exerted. Repeat with the other leg.


Knees
Usually only minor contractures develop at the knees before the child has to start using a wheelchair but it is essential to prevent these because it is difficult to stand or walk with bent knees. To stretch the knees the child lies on his/her back while the parent stands at the level of the feet, slightly to one side. Grasp the heel of the right foot with your left hand, your palm cupped and your fingers bent. With the other hand counter pressure is given on the thigh just above the knee–cap and the lower leg is brought up until the knee is straight. Be careful not to cause discomfort by over–straightening the knee. Repeat with the other leg.

Feet and ankles
The infant lies on his/her back while the parent stands at the level of the feet, slightly to one side. Grasp the heel of the left foot with your left hand, your palm cupped and your fingers bent. Extend your thumb up the side of the child’s lower leg. With the right hand grasp the foot and move it to a right angle. When doing this, check that the foot is straight i.e. that it is not turning in or out. The foot should be directly in line with the knee and the knee should be kept straight. Repeat with the other leg.

Elbows, forearms and wrists
Most children with muscular dystrophy have floppy elbows and wrists but some can develop tightness as they get older. The main stretch is to straighten the elbows while turning the palm of the hand up. Stand beside the child on the side of the arm to be stretched. For the left arm, cup the elbow in your right palm and put your left hand on the palm surface of the wrist. Turn the forearm as far round as possible so that his/her hand faces upwards and pull the hand down to straighten the arm as much as you can (without overstretching), holding this position for a count of five. Repeat for the other arm.

Active & Active Assisted Exercises
Active muscle work is where the child does the ‘Work’ himself/herself. This type of exercise helps strengthen muscles and may or may not be against resistance. Active assisted exercises are where the child and the helper work together to achieve a particular movement.

No matter how much exercise your child does, you cannot expect the muscles to become as strong as the ‘Normal’ muscle. However, most of the muscles in the body have the potential for increased strength with exercises and this will lead to some improvement in function and ability. In the weakest children, it may be difficult to notice much increase in power with exercise. The exercises are directed at the weaker of the muscle pairs in the arms and legs. The opposite pairs of muscles in the neck and trunk are almost equally weak but it is thought more important to exercise the ‘Extensors’, those that lift the head up and pull the trunk up straight, rather than the ‘Flexors’ which are the muscles which bend them forward.

The child lies over a roll resting on the forearms with the head down. The object of the exercise is to try to lift the head and push the arms straight.

Head & Trunk Extension
The child rests on the tummy and attempts to raise the head and shoulders to look up. The arms may be supported by the helper. Games such as pushing a ball can be incorporated into this exercise.


Chest Physiotherapy for Children
In Muscular Dystrophy, the muscles are weak, along with the other trunk and spine muscles. The children tend to use their diaphragm muscle more when breathing than we would normally, which is why they may develop a longer, thinner looking chest. When the children get a chest infection, the inability to take good deep breaths and cough forcefully may make the clearance of excess thick phlegm that occurs more difficult. This is when chest physiotherapy is useful to help clear the lungs and get the phlegm into the mouth where it can be spitted out. Chest physiotherapy works by helping to drain the secretions out of the lungs and get them to where they can be removed or swallowed.

The main techniques used are
Postural drainage
Postural drainage involves laying the children in certain positions, dictated by the shape of the lungs to allow gravity to help drain the secretions towards the mouth. In some chest infections, only specific parts (lobes) of the lungs have excess secretions, while in other infections most or all of the lobes will be affected.The most commonly used positions involve the child lying tipped head down over pillows on his/her back, front and sides. The other position used, mostly with small children, is sitting.
Percussion
This is when the child’s chest is clapped gently with cupped hands to help shake the secretions loose. Most children find this quite soothing and effective, even though it may sound as though it hurts.
Breathing exercises and ‘Forced expiration techniques’ (FET)
Breathing exercises are used to help the child increase air entry into the lungs, as effective deep breaths also help to loosen the secretions that occur as a result of the infection. There are several different ways of teaching deep breathing and FET (which is sometimes called ‘Huffing’)
Assisted coughing
This can be useful for very weak children who have a lot of difficulty getting the phlegm to the back of their throats to swallow it. It involves putting your hand under the diaphragm, on the child’s tummy and pushing firmly upwards to give more force to the cough. This technique is not difficult to do but needs practice to get the timing correct with the child’s attempt to cough.

Positioning & Seating in Muscular Dystrophy
The spine is a complicated series of bones joined together to allow bending forwards and sideways and for rotation to be possible. Normally, the spine is held straight by the action of many spinal muscles and the abdominal (tummy) muscles working together. In babies, these muscles are weak but get stronger in due course of time as they grow up, allowing for rolling, then sitting and eventually standing, walking and more complicated movements.

In muscular dystrophy, these muscles remain weak and could affect the child’s ability to progress towards their expected milestones of development. The shape of the spine then becomes affected by gravity pushing down, by asymmetrical muscle power (i.e. one side being stronger than the other) and by joint contractures, particularly in the hips.

Some very weak children may need to wear a spinal jacket to help them to sit. Others may need to start wearing a jacket when they begin school because they spend a lot of time sitting down. Some of them may need to start wearing one for intermittent periods of time, as they grow taller and need extra support. Standing is strongly recommended as it helps to strengthen their spinal muscles. It is an easier position in which to control symmetrical movements, and in a ‘Lordotic’ posture, (one where the child appears to be leaning backwards) rotation of the spine is much more difficult. Besides, standing also stretches the hips.

Standing may be done in a standing frame, in a swivel walker or in calipers, but it is very crucial that whatever the child stands in, his/her spine is held straight. It is never possible to say that the child’s spine will or won’t remain straight and in most cases there will be some deterioration in posture as the child grows. The important thing to remember is that exercises, standing and wearing a spinal jacket when advised, will lessen problems in the long term.

In some cases, spinal surgery may be recommended for an older child but the decision to go ahead will have to be taken by you, the child himself/herself and doctor, all of you put together. If surgery is not a possibility, then it is imperative that the spine is supported to help prevent further deterioration. Seating becomes a higher priority and it really can help. Positioning and seating are very crucial for your child to enable him/her to perform any function in the best possible manner. Besides, it goes a long way in helping to prevent spinal and joint–related problems.

As a baby, it is good and advisable for your child to go through the normal experiences of lying on the back, sides and tummy, even though he/she may find lying on the tummy, a position from which he/she can do very little. A rolled towel placed under the chest will help your child to try and push down through the arms and try to lift the head and trunk. Just because your child finds certain things difficult, there’s no reason why he/she shouldn’t try, because that would provide the child with some good exercise.

A good supportive seat is essential all along. A cradle is often too soft and a firmer seat is better. Baby bouncers and baby walkers should be avoided as they do little to improve posture and trunk control. There are many good high chairs in the market which are convertible to floor chairs. In the case of very weak children, special seating would be necessary and your therapist would be able to arrange for this.

Wheelchairs should also be supportive. Avoid those that have a bar at the front which cannot be removed. The back of the chair should be the type that could be brought up to almost the upright position for the child when he/she is awake, and only be reclined when he/she is particularly tired or sleeping. The foot rest should be at the correct height to prevent the feet from dangling or the knees being pushed up. The depth of the seat should support almost the entire length of the child’s thighs without digging into the back of his/her legs.