60 F isio te ra p ie , S e p te m b e r 1982, deeI 38, n r 3 RESPIRATORY PHYSIOTHERAPY IN PAEDIATRICS* L . M . D A V I D S , B.Sc. (Ph ys io) W it w a t e r sr a n d , B.A. ( H o n s ) , U .O . F . S .. Dip. Ed. Ph y si o th e r, P r e t . t SUMMARY The approach to respiratory phy sio th e ra p y fo llo w e d a t the R ed Cross W ar M e m o ria l C hildren’s H o sp ita l is described. An overview o f therapy f o r the neonate, the child a fte r surgery, the a cutely ill c hild a n d the ch ild atte n d in g the P hysiotherapy D epartm ent as an outpatient, is given. S tre ss is laid on tre a tm en t o f the child and n ot only his respiratory problem. IN TRO DUC TIO N W h e n c o n s i d e r i n g r e s p i r a t o r y p h y s i o t h e r a p y in paedi atrics, it mu st be u n d e r s t o o d th at one is not dealing with a sc ale d- do wn adu lt. O n e is d e al in g with a child wh o is dev el op m en ta ll y , m ent all y a n d intellectually a totally dif­ ferent being f r o m an a d u lt. Also, o n e is n o t deal in g with a child in isolation, b u t with a m o th e r - ch i l d entity. F o r a child to react positively to tr e a tm e n t, o n e needs the help a n d co­ o p e r a t io n o f the m o th er . F o r a n o r m a l psychological re­ spons e. the presenc e o f the m o t h e r is essential in all children u n d e r the age o f f ou r years a n d helpful in the o ld e r child. An y p h ys io th er a p is t w o r k i n g with b o t h in- a n d ou t p a t i e n t children will not ice a m a r k e d difference in th eir beh avio ur. O u t p a t i e n t c h ild ren a r e less c o - o p er a ti v e a n d pro tes t much more. M o s t o f the in pa ti en t children are good. These so- called goo d c h ild ren are no t re acting no rm all y. Re sp ir at o ry p h y s i o t h e r a p y is essentially a physical a t t a c k on the child a n d he sh o u l d react vi gorously to it. T h e in pat ien t child is being kep t in a n a b n o r m a l e n v ir o n m e n t . H os p it a li sa t io n is an u n de si rab le si t u a t i o n a n d sh o u l d be r e so r t ed to only in the last instance. H a l e s -T o o k e (1973) says “ A ft er seven m o nt h s o f age babies fret overtly in hospi tal , a n d up to the age o f at least fou r years sh ow signs o f suffe ring as a result of se p a ra t io n fro m th eir m o t h e r s ” . R E S P I R A T O R Y P H Y S I O T H E R A P Y F O R T H E NEONATE T he most fri ght en in g as pect of p aed iat ri c re spiratory th er a p y is the t r e a tm e n t o f the ne on at e. They are tiny an d frequently it is the p r e m a t u r e b a b y who requires chest tr e a tm e n t, viz the b a b y with r e sp ir at or y distress sy n dr o m e (hyaline m e m b r a n e disease). At full term delivery the lungs a r e no t fully developed. T e r m i n a l air sacs are sha llo w a n d wide n eck ed a n d therefore pa te n t , bu t there is a limited a r ea for gas exchange. Lun g g r o w t h c o nt in u e s with b r o n c h io l a r division a n d increases in n u m b e r a n d size o f the alveoli, t hu s in creasing the a re a for gas exchange. T h e n u m b e r of alveoli a n d airw ays increases ten times f r o m b ir th to a d u l t h o o d . Lu ng surface area increases tw en ty times. In the p r e m a t u r e i nf ant the lung is even more und e rd ev e lo pe d . T he u p p e r r e sp i r at o r y tract is p r ed is po se d to ob st ru c tio n. The nasal passa ges are n a r r o w a n d the in fan t is an o bl iga to ry nasal b r e a t h e r for the first fou r weeks of his existence. The glottis a n d t r a c h e a are o f small calibre a n d the relatively * Lecture delivered to H o s p ita l G r o u p o f the S.A.S.P. 19 S e p te m b e r 1981. f Princ ipal P h y s io th e r ap is t, R e d C ro ss W a r Me m o ria l C h i ld r e n ’s Ho sp ita l. Received 17 F e b r u a r y 1982. O P S O M M I N G Die benadering to t respiratoriese fis io te r a p ie soos toegepas by die R o o ik ru is O orlogsgedenkhospitaal vir K inders word o m skryf. 'n B eskryw in g van terapie vir diepasgebore baba, die k in d na chirurgie, die k in d wal ernstig sie k is en die k in d n at as buite-pasient die Fisioterapie D e p a rte m en t besoek, word gegee. D ie behandeling van die k in d en nie net sy respiratoriese to e s ta n d nie, w ord beklem toon. large to ng u e can easily o bs t r u c t res pir ation. T h u s any o e d e m a o f the larynx o r t r ac h ea can easily cause an o b s t r u c ti o n . De cre as e in the size o f the l um en will cause an increase in a irw ay resistance. Th e d i a p h r a g m is the mo st i m p o r t a n t muscle c£~ re sp ir at io n in the ne w b o r n . T h e r e is vi rtually no costm^. ele ment to respi rat ion . T h e ribs a r e h o r i z o n t a l so there is no bu c k et ha n dl e m o tio n . T he relatively large v o lu m e o f a b d o m i n a l c on te n ts with disten sio n o f the gas tro -inte stin al trac t can readily c o m p r o m i s e d i a p h r a g m a t i c action. W h e n re sp ir at io n is c o m p r o m i s e d , inter cos tal , sub co sta l an d st e r n al re tra ct io ns a r e evid en t be cause o f the c o m p l i an t car t il a g in o u s t h o r ac ic wall. Thes e are so m e o f the principal str uc tur al differences which d e m a n d a d a p t a t i o n o f p h y s i o t h e r a p y tec hniques. As the child grows the difference in tech ni qu es between child a n d a d u lt diminishes. T he most c o m m o n c o nd iti on s which might require re sp i r at o r y p h y si o t h e r a p y in the ne o n at e are: • R e s p i r a t o r y distress sy n d r o m e • T r a c h e o - o e s o p h a g e a l fistula • N e o n a t a l t e ta n u s • P n e u m o n i a (often c au s ed by a s p i r a t i o n o f milk) It is not possible to discuss tr e a tm e n t regimens for any specific c o n d it i o n , bu t so m e a d a p t a t i o n s will be detailed. T h e fingertips are used for percus si on in an in tu b a te d infant. C a r e mu st be ta ke n not to shift the tu be with too v ig o r o u s a p pl ic at io n . Perc uss io n can cause b r e a k d o w n o f the a na s to m o s i s in a t r a c h eo - o e so ph a g ea l fistula with an e n d - to - e n d a n as to m o si s. This type o f case is suitable for tb f - ap p li c at io n o f an electric to o th b r u s h . If m a n u a l v i br ati on used c ar e m u st be ta ke n not to squeeze the th o ra c ic wall too h a r d be cau se fr ac tu re s m ay be caused. T he t r e a t m e n t session sh o u l d be kep t sh o r t be cause the in fan ts tire quickly a n d easily b e co m e distressed. O n e must watch for recession, ta c h y p n o e a a n d m ottling. Bag- sq u e e zi n g is used when tr eat in g a n i n t u b a t e d bab y. At the end o f a t r e a t m e n t session o n e m a y ba g to help raise the P a O : If se cretions are thick a n d c a n n o t be su ct io n ed easily, saline can be used to thin them. T h is is ad m i n i st er e d 0,5 ml at a time. T h e d i a m e te r o f the s u c tio n in g c a t h e t e r sh o ul d be a b o u t 50% o f the d i a m e te r of the tu be be cause suction ing c o u ld collapse the i m m a tu r e alveoli, especially in the case o f r e sp i r at or y distress syn dr om e. If the infan t is n o t in tu b a t e d , oral su c t io n i n g sh ou ld be use d as nasal s u c tio n in g o f a n e o n a t e can be d a ng er ou s, especially if he has a n a so g a str ic tu be in situ. I f b o t h nostrils are b l o ck e d the infan t c a n n o t b re at h e. Or al suc tio n in g o f a b a b y with a re pa ir o f a t r a c h eo - o e so p h a ge a l fistula, w h o is n o t in tu b a t e d , can cause d a m a g e to the a n a s to m o si s. The exact length o f c a t h e t e r th at m ay be safely inserted m u st be a sc er ta in e d fro m the surge on. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) p h y s io th e ra p y , S e p te m b e r 1982, vot 38, n o 3 61 RESPIRATORY PHY SIO TH ERA PY IN THE ACUTELY ILL C H IL D AFTER SURGERY Unless the child has u n d e r g o n e em e rg en c y surgery he sh o u l d be tr ea te d pre- as well as post-o pe rat ive ly . It is very i m p o r t a n t to p r e p a r e the child psychologically as well as physically f or an o p e r a t io n . T he m o t h e r a n d the child sho ul d be p r e p a re d tog ethe r. In the c ar d i ac su rg er y unit the m o t h e r a n d child are tak e n to the unit a n d the a p p a r a t u s is explained to the m o th er . D e p e n d i n g on the age of the child, everything is explained to him so th at he kn o w s wha t to expect. One may have to clear the chest if the child is at all pr oductive. H e will be t au gh t deep b r e a t h in g a n d effective coughing. A s p u t u m spec imen is ro ut in el y taken. I f the child is o f an a g e th a t he can u n d e r s t a n d it. the whole p o s t ­ operative ph y sio th era py rou tine is d e m o n s tr a t e d o n him. The t echniques are sim ila r to th o se used on an adult. To e nco urage deep br e at hi n g, an i n sp ir o m e te r m a y be used. Postural d ra in a g e is usually d o n e in a lt e rn a te side lying. If the child is t o o y o u n g to c o u g h to c o m m a n d a n d to | expectorate, he m ay be su c tio n e d orally, o r nasally if he tends to vomit. If necessary, light trac hea l pres sur e m a y be used to elicit an effective co ug h. W he n t ak in g a s p u t u m specimen, the cheeks are held to prev ent the child fro m swallowing the secretions. P o st- op er ati vel y the child m ay be i n tu ba te d . He is given ro ut in e r e sp i r at or y th er a py such as a lt e rn a te side lying with pe rcussion, v i b r at io ns with bag -sq uee zin g a n d use of saline if the secret ion s are thick o r plugging. Du ri ng tr eat m en t the pe rc e n ta ge o f oxygen ad m i n i st er e d m ay be increased to prev ent t o o s h a r p a d r o p in the Pa O ,. T h e most c o m m o n po st - o p e r a t iv e l un g c o m p li ca tio n s a r e right u p p e r lobe atelectasis a n d left lower lobe collapse in the valve replacements. If the child is n o t in tu b a t e d , he mu st be suct ion ed if he coug hs ineffectively. T ra c he a l pres sur e sh o u l d no t be used imm ediately po st- ope rat ive ly be cau se o f the d a n g e r o f causing st rido r. T he child m ay be tr ea te d f ou r times per day initially, d e p e n d i n g on his c o n d iti on . An u n c o m pl ic a te d po st- ope rat ive co u rse sh ou ld n o t require th er a p y fo r longer than three to f ou r days. RESPIRATORY PHYSI OT HE RA PY IN TH E ACUTELY ILL CH ILD The most c o m m o n r e sp i r at or y c o n d it i o n s seen in the m ed ic al w a r d s a r e p n e u m o n i a (v i r al , p o s t - m e a s l e s , ^staphylococcal, etc), paralysis o f the muscles of re spiration in G u i l l a i n - B a r r e s y n d r o m e , b r o n c h i o l i t i s , s t a t u s as th m a tic us a n d l ar yn g o- t r ac h e al bronchitis. If oxygen th er a p y is r e qu ir e d for an i nfan t o r small child, it is a d mi ni ste re d in a h e ad bo x . A n oxygen m o n i t o r sh o ul d be used with a h e a d b o x . W h en p h y si o t h e r a p y is given, the child sho ul d be tr ea te d u n d e r oxygen. Sec retion s are re m ov e d by oral a n d nasal suction ing . The child with l a ry n go -t ra c h e al b r o nc h iti s w h o requires a tr ac h eo s to m y m ay be co m e a l on g- te rm p a ti e n t if e x tu b a tio n is unsuccessful. Po rt e x t r a c h e o s to m y tubes with c on n ec to r s are used. H u m i d if i c a t io n is ad m i n i st er e d via a m a s k th at fits over the co nn ec to r. T h e i nfa nt is n ur se d o n his bac k with his neck ex te n de d o ve r a roll plac ed u n d e r the sheet. No pillows are allowed. T h e r e is thu s little d a n g e r o f the child fle x in g his neck a n d o b s t r u c ti n g the tube. T h e b a b y is tr e a te d twice a day using percu ss ion , v ib ra ti o ns a n d suc tioning. The nurses also suction wh en eve r necessary. O ld e r child ren are given spea king tr a c h e o s to m i e s if they a r e ke pt in hosp it al for any length o f time. They m ay be tr e a te d daily o r less frequently, dep en di ng o n th eir c o n di ti o n. When a child is e x tu b a t e d , he is ke pt qu iet ly in bed f or 2-3 hours before p h y si o t h er a p y . T h e n the child is tr eated n o r m al l y , suc tio ne d ora lly a n d e n co u r a g ed to cough. He is also s u c tio ne d via the s t o m a usin g a m uc u s a s p i r a t o r to ascertain the a m o u n t o f residual secretions. If the child is able to c o ug h effectively a n d clear the secretions, he sh o ul d rema in extu ba ted . L o n g term t r a c h e o s t o m y leads to a de v elo p m en tal pr ob lem and an y p hy si o t h er a p i st wo rk in g with these p a tie n ts sh ou ld be a w a r e o f this. T h e y often c a n n o t be sent h om e a n d thu s need a to tal care p r o g r a m m e involving the p a r en t s if possible. While they are bab ies they need toys a nd the o p p o r t u n i t y to move nor mal ly . As they m a t u r e they need more s op h is ti ca te d play a n d as m u ch everyd ay experience as possible i.e. play outsi de, sa nd , w a te r, o ut ing s etc. Ideally they also need the s a m e care-giver to en su re a stable upbrin ging . RESPIRATORY PHY SIO TH ERA PY FOR TH E C H ILD IN THE OUTPATIENT DEPARTMENT In the o u t p a t i e n t d e p a r t m e n t o n e most freq ue nt ly sees p n e u m o n i a with c o ll a p s e / c o n s o l id a t io n a n d bronchiolitis. Effective t r e a tm e n t includes e d u c a t o n of the m o th e r . I f the m o t h e r do es no t treat the child at h o m e , th e r a p y c a n n o t be really successful. Po s tu r a l d r a in a g e is d o ne o ve r pillows a n d a tiny b a b y can be d r a in e d on the lap. T he child is percussed, v i b r a t e d a n d suc tio ne d ora lly o r nasally. J a c q u e s cathet er s are used t o p re ven t t r a u m a to the m u co s a. O ld e r children are e n c o u r a g e d to c o ug h a n d ex p ect or at e. Spe cimen j ar s mak e very useful di sp o sa b le s p u t u m mugs a n d the a m o u n t o f sp u t u m is easily m ea sur ed . If the child coughs effectively a n d swallows the secretions he need n o t be suct ion ed . The m o t h e r is t au gh t to percuss a n d d r a i n the child; if the child does no t c o u gh o n pe rcu ss io n the m o t h e r m ay be given some c at h e t e r s a n d be t a u g h t h o w t o s t i m u l a t e a cough. With some o f the ol der, p r o f o u n d l y r e ta rd ed children with cerebral palsy, o n e may teach the m o th e r h ow to a pp ly tracheal pressure. P os tu ra l d r a in a g e can be d o n e at h o m e o ve r an u p si d e - d o w n ch air with pillows on it. G r e a t stress is laid on the im p o r t a n c e o f the m o t h e r t r ea tin g the child twice a day. THE C H IL D WITH C H RO NI C RESPIRATORY DI SEA SE F o r a n y p h y s i o t h e r a p i s t d e a l i n g w i t h p a e d i a t r i c re sp i r at o r y cases, the child with ch r o n ic r e sp i r at o r y disease, suc h as extensive, in o p e r a b le bronch iec ta sis o r fibrocystic disease, can be the most difficult to handle. T h e tr ea tm e n t consists o f po st u ra l d r a in a g e in all posit ions, percussion, v ib r at i o n , possible n e b ul i sa t io n a n d effective coughing. T h e r a p y is a im e d at ke epi ng the chest clear a n d prev ent ing acut e chest infections. T he m o t h e r a g a i n is the key figure in the t r e a t m e n t o f these children. She needs c o n s t a n t s u p p o r t from the d o c to r s a n d ph y si o th er a p is ts a n d she must u n d e r s t a n d the i m p o r t a n c e o f r o ut ine ly t rea tin g the child w he th er he is well o r ill. As s o o n as cystic fibrosis is di ag n o s ed the m o t h e r is sent to the P h y s io t h e r a p y D e p a r t m e n t to be t a u g h t po st u ra l dr a in a g e a n d percu ss ion . Babies are po sit io n ed o v e r pillows in side lying on a lt e rn a t e sides a n d are also posi tio ne d in sitting. T h e m o t h e r is t a u g h t to percuss each a r ea for 3-5 m in u t e s a n d the child is tr eat ed twice a d a y befo re meals. The m o t h e r is t a u g h t h o w to st im u la te a co ug h with a Ja c q u es c at h et e r if the child is at all pr o d uc tiv e. As the child grows older, she must teach him to c o u gh effectively a n d exp ect or at e. D e p e n d i n g on the child, he will c o ug h to c o m m a n d at a b o u t 2 ' / 2 years o f age a n d be able to ex p ec to r a t e p r o pe rl y a t a b o u t V / 2 years. T h e m o t h e r is later t a u g ht to v ibrate the chest, but as the child g ro ws the p u r c h as e o f a m ec han ic al v i b r a t o r is e n co u r a g ed . This is R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 62 F isio te ra p ie , S e p te m b e r 1982, de e l 38, n r 3 especially useful when the child c o m p l a in s of pa in on pe rcussion. W h e n the child re quires re g ul ar neb ulisatio n with a mu coly tic a ge nt ( M is ta b ro n 2:2 ml saline), the pa re n ts will need a c o m p r e s s o r uni t which can be a d a p t e d for dispos ab le nebulisers. As the child grows, pillows become less useful for po st u r a l dr a in a g e a n d the p u r c h as e of a foam wedge is advised. R e sp i r at o r y p h y s i o t h e r a p y must be com e a p a r t o f the c h ild ’s n o rm a l daily routine. Advice a b o u t ga m e s a n d s por t is also given. T h u s the child needs to a tt e n d the P h y s io t h e r a p y D e p a r t m e n t only when he has an acut e chest infection, bu t the p a r en t s k n o w th at they can co me at any time for advice a n d / o r tr ea tm e n t. C O N C L U S I O N S o m e aspects o f r e sp i r at or y p h y s i o t h e r a p y in children have been t o u c h e d on. T h e t ec hn iq ues used on a d u lt s are also used on ch ild ren , bu t a d a p t e d for the size a n d c o nd iti on o f the pati en t. It must be u n d e r s t o o d th at the child is in the process o f d e v el o p in g a n d in o r d e r to t r ea t him with m ax im um effectiveness, his stage o f physical, intellectual a n d em o t i o n a l d e v el o pm en t sh o u l d for m the basis of the th er a p eu t i c a pp r o a c h . References H a l es -T o o ke , A. (1973). C h i ld r e n in hospit al — the p a r e n t s ’ view. Pr io r y Press. L o n d o n . Levin, R. M. (1976). Pa e di a tri c r e sp i r at o r y intensive care h a n d b o o k . Medical E x a m i n a t i o n P ub . Co. Fl ush in g, N.Y. R o b e r ts o n , J. (1977). Y o u n g childr en in hospi tal . 2n d ed. T av is to ck . L o n d o n . Sm ith , C. A. ed. (1977). T h e critically ill child, di agnosis a n d m a n a g e m e n t. 2nd ed. W. B. S a u n de r s. Phil ade lph ia. HIP ADDUCTOR MUSCLE RELEASE IN THE TREATMENT OF CHILDREN WITH CERERRAL PALSY B E V E R L E Y T R A U B , B.Sc. (Physiotherapy) (Witwatersrand)* & C O L L E E N P I T C H F O R D , B.Sc. (Physiotherapy) ( Witwatersrand)* T h e aim s of this stud y are: • to describe the p o s to p e ra ti ve m a n a g e m e n t o f a d d u c t o r muscle release patients. • to fo r m u la t e a de tailed p o s to p e ra ti ve ph y si o th er a py p r o g r a m m e t o e n a b l e a c c u r a t e e v a l u a t i o n a n d p ro g n o st i ca t io n . In a retr os pec tiv e st ud y we have sh o w n th a t the results a c h i e v e d u s i n g this p r o c e d u r e a n d p o s t o p e r a t i v e m a n a g e m e n t p r o g r a m m e are very satis fac tor y in ter m s o f the success ra te a n d e n d results. T his o p e r a t i o n is p e r fo rm e d on c ere br al palsied children w h o are i n c a p a c i ta t e d d ue to m a r k e d spa sticit y o f the hip a d d u c t o r muscles, which results in a scissoring gait on a t t e m p t e d a m b u l a t i o n , as well as re du ced a b d u c t i o n range whic h m a y be so severe as to cause su b l u x a ti o n of the hips. T his s u b l u x a ti o n n o r m al ly oc c u r r i n g in child ren with less t han 30° o f t o t a l a b d u c t i o n m a y pr ogr es s to fr a n k dislo ca tio n a n d its a t t e n d a n t c o m p li ca tio n s. T h u s , the ind ica tio ns for this p r o c e d u r e may be f o r m u la t e d as follows: • scissor gait with a m b u l a t o r y im p a i r m e n t • t h r e a te n e d s u b l u x a ti o n o r i m m in en t disl oca tio n • difficulty in n u r si n g the severely spastic child. SUR GICA L PR O CE DU RE T h e success o f the o p e r a t i o n is d e p e n d e n t o n a n u m b e r of factors: A g e o f the p a tie n t No r m a ll y the o p e r a t io n is p e r fo r m e d o n c h ild ren between the ages o f f o u r a n d six years f or pract ica l pu rp os e s, i.e. difficulty in the a d e q u a t e assessment o f a b d u c t i o n str en gth in a child o f u n d e r three years, u n d e r s t a n d i n g an d i n te r p r e t a ti o n by the child etc. * D o n e whilst p h y s io th er a p is ts at N a t a l s p r u i t Hosp ita l. Received 26 O c t o b e r 1981. H om e a n d f a m ily b a c kground T his is k n o w n to have an effect on po st o pe ra ti ve m a n a g e m e n t , bu t in o u r sho rt stud y all the child ren were of sim ila r b a c k g r o u n d (b o a rd i n g sc hool) a n d this p a r a m e t e r was unassessed. A d eq u a te p o sto p era tive care A d e q u a t e p o s t o p e r a t i v e c a re im p li es s a t i s f a c t o r y an alg es ia, m o ti v a te d n u rs in g staff a n d a n ti bi ot ic cover. P o s to p e ra tiv e ly the child is imm ob ilised in a plas ter spica for 3-4 weeks. T h e cast is ap p lie d with the hips in full a b d u c t i o n a n d exte nsi on with 10°-15° exte rnal ro t a t i o n . T oe to gr oin casts j o in e d by a n a b d u c t i o n b a r sh o u l d no t be used as they i n va ri ab ly lead to pelvic o bliqu ity. A p pr o x i m at el y two day s po st o p e ra ti v el y the P o r t o v a c c ath ete rs a n ^ re m o ve d , prov id ed they are no long er d ra ini ng . S h o u l d there be n o co m p l i ca ti o n s, the p a tie n t is di sc ha rg e d a p p r o x im a t e ly tw o weeks later in the care o f their pa re n ts with in structi ons re g ar d i n g fol low -u p eare. In o u r st ud y all the child ren were resident at the Ezebeleni H o m e for di sa b led children an d thu s re m a in e d in ho spital d u r i n g the three weeks of imm ob ili sa tio n . F o ll ow in g remov al of the cast the w o u n d is inspected. Sho ul d the w o u n d be septic o r pa rtl y o pe n, tr e a tm e n t in the h y d r o t h e r a p y pool (a m aj o r pa rt of the p h y s io th er a py t r e a tm e n t) is obv iou sly c o n tr a - in d i c a t e d . An alt ern at e p r o g r a m m e for these septic cases mu st be a d o p te d. PH YSIO THERAPY Week 1 Pain in the hips a nd knees was fo u n d t o be a c o n st an t p r o b l e m in the t r e a tm e n t o f these cases. H y d r o t h e r a p y was used for the first 3-5 day s a n d this r esulted in go od pain relief a n d all ow ed freer m o ve m e n t. T h e pool p r o g r a m m e followed was: • Passive m o v em e n ts o f the hips, knees a n d ank les with special a tt e n ti o n to m a i n t a i n i n g hip a b d u c t i o n as well as R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )