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Biomechanical intervention for 3yr old?

Discussion in 'Pediatrics' started by Princess, Jun 13, 2008.

  1. Princess

    Princess Active Member


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    Hi all,
    I've just been informed that I have a lady bringing in her 3yr old son for a biomechanical assessment next week.
    My personal view on the topic is that I wouldn't intervene until hip rotation stabilises - but wondered what the general consensus is?
    Can we cause more damage intervening now?

    As always the issue is dealing with the parent not the child in these cases.

    Any advice would be gratefully recieved!!

    Regards
     
  2. Boots n all

    Boots n all Well-Known Member

    "Can we cause more damage intervening now?"

    Can we cause more damage by not intervening now?

    l would wait until you see the child first before you make a decision about whether intervention is right or not and as to what you call intervention?

    Most of the children that we see (excluding the ones referred from the "early intervention centers") only need a decent pair of lace up shoes, some stretching exercises and more running around at that age, those that we feel need more we refer them on to an Osteopath first to see that there is no problems with ROM else where and that they are okay with what we are planning to do, l love second opinions when it come to children and the parents will appreciate your caution:D.

    When children first arrive at our place we leave them to play for a bit, this ensures that they are relaxed and that they are not stiff and tied from a nap in the car on their way over as some travel up to 2 hours to get here sometimes :wacko: l am sure there is someone closer to them
     
  3. Bug

    Bug Well-Known Member

    I agree with David. Until you know what she is coming in for, you can't make that judgment. There is a lot to be said for early intervention.

    In the case of low tone, intervention to assist with joint stabilization is important so the child can begin to meet the milestones they won't be able to meet with that instability. If the child is intoe or outtoe walking, assessment of the case, be it foot, tibila rotation or hip is important to determine early to begin treatment early.

    Shoes are an important tool in the tool box or treatment methods of children as is a good background in strengthening and stretching programs and games that are suitable for kids. Likewise the knowledge of gross motor skills and what is normal biomechanics is imperative.

    Good luck and if you get stuck there are many people here that will give you advice :)
     
  4. Trent Baker

    Trent Baker Active Member

    I also agree here. You never knock back a patient because you feel they are too young for intervention. There is more to do here than intervene. Some of these kids may have more significant problems going on, that nobody has picked up on. There is no issue with screening these kids and recording baselines to work from later if required at the very least. You would hate to miss a real problem because you didn't even look at the child.

    In term of intervention, the above comments are very valid. However you must always take each child on a case by case scenario, this way you will never miss anything.

    Trent
     
  5. Adrian Misseri

    Adrian Misseri Active Member

    I also concur here. Just brush up on your developmental milestones and reflexes present/absent at about this age. Just make sure that normal development is occuring, and see if any variation will fall withing a normal range. I guess my ideas for a child at this age is that if there's any major issues, they will be very obvious...
     
  6. Stanley

    Stanley Well-Known Member

    Most children are coming to see you for either intoe gait or "flat foot". 3 years of age is too late for some interventions (ie: cast correction for calcaneal valgus or metadductus, or Denis Browne spints for "tibial torsion").


    Regards,

    Stanley
     
  7. PodGov

    PodGov Member

    I agree with the comments and suggestions given thus far. Suffice to say that it may be the parent/guardian who may need most of the convincing on the final rationale of the management plan, based on the merits of the case, once assessed.
     
  8. Adrian Misseri

    Adrian Misseri Active Member

    I agree, sometimes telling the parent that their child is a happy, healthy, normal child, who obviously is keping up with others and developing along as they should can be the most importent part of the consult, when you assess the child to be developing along as they should of course.

    Cheers!
     
  9. Bug

    Bug Well-Known Member

    That is such a valid point.

    How often do we brush up on our developmental norms? Do we all know when a child should jump and hop and for how long on their dominent and non-dominant leg.

    As podiatrists, do we continue to learn from our fellow allied health professions about the tone, length and strength of muscles and how they globally impact a child and their gait.

    No answers....just Wednesday night musings.
     
  10. Wendy

    Wendy Active Member

    Appologies for resurrecting this post and I have read the responses with great interest.
    Princess how did you get on?
    My situation is similar in that the child has been refered to me by his osteopath as the pod he saw previously has moved away.
    Apparently the child had orthotics prescribed approx 18mths ago. I have spoken to the mother and she is concerned as the pre school the child attends advised he is tripping regularly. Would the advice differ from that already given?
    Thanks in advance.
     
  11. Princess

    Princess Active Member

    Hi Wendy,
    In my opinion the child was "normal" if anything the tripping up that the patient's mother was concerned about I think was more related to really heavy footwear than the childs gait , as there was no issue when the child was barefoot and the child was in a heavy trainer that had laces that weren't tied. I gave all this information to the mother including footwear advice - ahe also had an appointment with the local authority biomechanics specialist a month or so after me - so I recommended that she kept that appointment - as a second opinion and as they were likely to have more podopaediatric experience than I do.

    Regards
     
  12. jos

    jos Active Member

    I agree with all the previous posts and at least they have made the appt with a pod.! A couple of years ago, I had concerned parents ringing me for 'second opinions' after they had visited a myotherapist and been given orthotics for their child, after being told that their children would be 'crippled' in one case and 'not able to do ballet anymore' in another case...............all 'scare tactics that obviously worked.
    The best one was a mother whose 16month old refused to wear her shoes with the orthotics. When I asked how long she had been walking, the mum replied "oh, she's not walking yet, I was told that she had to wear these shoes all day, though". The child spent the best part of the day sitting, trying to pull off the wretched shoes................................
    So, my advice is as the others - assess and don't be afraid to find anything normal!!
     
  13. Bug

    Bug Well-Known Member

    :eek: Why is this still going on? I just don't understand. :wacko:
     
  14. Whats wrong with that?

    Ok. I'll grant that 16/12 is a bit early. But in the multidisciplinery teami work with (physio, orthotist, podiatrist) we often used surgical footwear (which are, of course, orthotics) in children before they are walking. Delayed walking is often the presenting sign for gross hypermobility. I have seen a child of 20 months, not yet walking, with hypermobility so severe that the second - 5th met heads were all non weight bearing when the child stood supported. Without some fairly serious support that child would have had real difficulty walking and the angles and forces would, i beleive, had put those joints and ligaments in serious jeapordy.

    So i have no problem with using orthotics in some children before they are walking.

    Regards
    Robert
     
  15. jos

    jos Active Member

    Of course, there are the rare ones that may need it BUT in this case they were issued by an over zealous myotherapist who couldn't recognize that a fat pudgy foot in a 16 month old is NORMAL and not 'flat' and certainly NOT in need of orthoses!!
    That was the point I was making!!
     
  16. Bug

    Bug Well-Known Member

    I get where you are coming from Robert but 16 months, even at that age a child with that amount of hypermobility would not even be attempting to stand/cruise. Unless there had been a diagnosed disability/GDD/genetic syndrome etc, yes, but when there is no other indication that there is problem.

    I work on an early intervention team and often put young kids in various forms of wedges and footwear from 20+ months when needed and there is delayed walking. However, that age, with that sort of problem, we all know is the smallest minority.

    I also think we need to be quite clear about what we are referring to when we use the big O word. As podiatrists know that an orthotics can be a shoe, a shoe with mod's, a rf wedge, a ff wedge, a triplanar wedge, functional orth, off the shelf etc etc etc when the majority of the medical and allied health profession hear/read orthotic and they just think a $500 device.

    So, while I agree with the sentiment, I think the reaction to the statement of a 16 month non-ambulant child in orthotics AND shoes should prompt a bit of a negative reaction.
     
  17. Hey Bug / Jos

    As you say that would be an unusual case at 16 months. And i'm not sure that an in shoe orthotic would be the path to joy for stability at that age in any case (transverse plane control much easier in a foot that small.) So i do see where you are coming from. ;). I just thought it was making the point that this is not universally a bad thing to try to encourage hypermobile children to wear shoes before they start walking.


    This however
    Is utterly indefensible and more than a little contemptable and should be stamped on hard!:mad:

    Kindest regards
    Robert
     
  18. What the hell is a myotherapist anyway?! Physio lite?
     
  19. Heather J Bassett

    Heather J Bassett Well-Known Member

    Hi Robert thanks your input as always, I still love the humour, it is great to get a smile with many of your posts, now I am running late to pick up my paeds from school.

    Cheers
     
  20. Sally Smillie

    Sally Smillie Active Member

    Hi Robert,

    I would agree, but only to a point. Surgical footwear (we use Piedro's, I assumme you use something similar?) do provide ankle support, but for the child you mention above, they will continue to have pes pancakus within the shoe - you just can't see it and thus everyone feels better about the whole thing. For such a child, I find if they are as severe as the child above (and I see plenty of them), they really need an in-shoe device (such as FIM5/Gecko's etc) as well as the boot.

    Physio's go a bit overboard on their Piedro's I find. Great for ankles, do nothing for foot posture. I'd love to do a weight bearing XR study to demonstrate this to the physio's, but don't fancy my chances of getting past ethics ;)

    This is assuming of course, that either you or the physio's have been working on sit-to-stand and building up quad strength etc. What we tend to do, is if we feel this intervention is indicated, we implement it at the beginning of cruising stage or at pull to stand. What you don't want is a child crawling in those boots.
    I think the minimum intervention is best - we might try a FIM inside good supportive trainer first, and hold off on the boots until it is apparent that it really is necessary.

    All the best,
    Sally
     
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