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. ) P hysio th e ra p y, S e p te m b e r 1982, vol 38, n o 3 63 ga in in g full ran ge o f knee a n d a n k le joi nt s. (Initially it may be difficult to achieve a full r a ng e o f m o v em e n t a n d no forceful m a n i p u l a t i o n sh o u l d be e mp lo ye d; usually how ev er, bv the third day o f t r e a tm e n t, the requisite range o f m o v e m e n t h a d been achieved.) • A s si st ed /a ct iv e exercises. Thes e sh o u l d include: Supine: • Hi p a b d u c t i o n a n d a d d u c t i o n • Hi p flexion — str aig ht leg raising — d r a w i n g knees to the chest • H i p a d d u c t i o n — squeezing a ball between the legs Prone: • H i p extension • Knee flexion a n d ex tension Silling: • An kl e dor siflexion a n d pl an ta rfl ex io n • Knee flexion a n d ex tension over the edge o f the step (in the po ol) Side lying: • Hi p a d d u c t i o n a n d a b d u c t i o n Kneeling: • Pe rf or m weight transfere nce from o n e kne e to the o t h er Standing: • W a t e r waist high; a lt e rn a t e hip flexion t h r o u g h to extension • A t t e m p t e d walking. Week 2 Once the fu nc tio na l range o f the we ig ht -b e ar in g jo int s is attai ned a n d active exercises a r e being ad eq u a te l y pe r fo r m e d by the pati en t, s t a n d in g a n d walking, u n d e r super visio n, in the parallel bars are allowed. One imm e di a te p r ob le m pr es en te d at this point. The children persistently flexed at the knees when a tt e m p t e d weight be ar in g th r o u g h the hi p j o in t p r o d u c e d pain. De spit e co n ce rte d a t t e m p t s to pr event such knee flexion (which conceivably c o u ld lead to fixed flexion de fo rm i t y ( F F D ) of the knees) it was unsuccessful. (This pain m ay be du e to a n u m b e r of factors, such as incisional pain which m ay be present for va ria ble pe riods o r pain fro m the im mobilised join ts d u e to o st e o p o r o si s a n d jo in t stiffness.) Analgesia was n o t used be cause o f the logistics o f a d m i n i s t r a t i o n a nd timing to achieve m axi m al effect at the time of ph y sio th era py , a n d the ever present d a n g e r o f de pendence. We a t t e m p t e d to pr e ve n t kn ee flexion using backs lab s, but fou n d th at a d e q u a t e knee exte nsi on was im possible to m aintain. F o r these re asons, the children were placed into cylinder p laste rs. T hi s fo rce d the child to be a r weight t h r ou gh the hips with the knees exte nde d. Th er e was imm ed iat e i m p r o v e m e n t in the gait. D u r i n g this time m a i nt en a n ce exercises c o n ti n u e d (refer to the exercises p e rf o r m e d in the po ol ; n o w p e r f o r m e d on a m at), as well as daily passive str e tc h i n g o f the ad d u ct o r s. Onc e the child was w al kin g well ( 4- 10 days), the cylinder plasters were remov ed . It was f o u n d that flexion of the knees did not re cur a n d the gait r e m a in e d acceptable. D e p e n d i n g o n the rate o f pro gre ss , the c hi ld ren were plac ed in rolla to r walkers o r o n crutches. Week 3-4 D u r i n g this ph as e it was f o u n d th a t all the children were either in walkers, on cr u tc he s or w al kin g u n a id e d . T h er e was n o p r ob le m in m o ti v a ti n g the p a tie nt s a n d the trans ition from wa lk er to c r ut c h es to u n a i d e d a m b u l a t i o n was easily acc omplished. After 4 weeks After the initial intensive fo u r- we ek p r o g r a m m e o f daily p h y si o th er a py , the child on ly at ten d e d t hr ee times a week for u p to six m o nt h s . D u r i n g this p e r io d, the children were all fol lowe d up f o r evidence o f c o nt r a ct ur e s. In one case this o c c u r r e d a n d night splints were used to treat possible flexion d e fo rm it ie s o f the knees d u e to tight h a m s tr i n g muscles. C O N C L U S I O N O f the five p a tie n ts studied, th ree were able to att ain u n a i d e d gait a n d this was achi eve d within f o u r weeks fro m the be gin ni ng o f active ph y si o t h er a p y . (This was d u e to their less severely spastic c o n d it i o n as all were spastic diplegics.) T he o t h e r two p a ti e n ts c oul d n o t walk u n a id e d d u e to di sa b lin g spasticity in o n e case a n d triplegia in the ot her . Success is a t t r i b u t e d to: • daily ph y si o t h e r a p y • da ily passive str e tc h i n g o f the a d d u c t o r s • m a i n t e n a n c e o f a d d u c t i o n ra nge • the fact th at the c hil dr en were e n c o u r a g e d to sleep prone. Because o f the abo ve it was f o u n d u nn ece ssa ry to e mp lo y night splints for m a i nt ai ni ng ab d u ct i o n . Bibliography C ra ig J. J. (1967). Ce rebral palsy. M o d e r n tr end s in O r t h o p a e d i c s 5, 44-69. Salter R. E. ( 1 970). T e x t b o o k o f dis or de rs a n d injuries o f the musculo sk ele tal system. Williams a n d Wilkins pp. 97-106. S h a r r a r d W. J. W. (1973). Pa e di a tri c o r t h o p a e d ic s a n d fr actu res. Blackwell, pp. 545-549. T a c h d ji a n M. O. (1972). P a e d ia tr ic o r t h o pa e d ic s. S a u n ­ ders. pp. 811-815. F IR S T E U R O P E A N C O N F E R E N C E ON R E S E A R C H IN RE H AB I L IT A T IO N 6-8 A P R I L 1983 T h e F i r s t E u r o p e a n C o n f e r e n c e o n R e s e a r c h in Re ha bi lit ati o n will be held in E d in b u r g h from 6-8 April. It is being org anised by the R e h ab i l it a t i o n St udies Unit o f the University of E d in b u r g h on b e h a l f o f the Society for Re search in R e h a b il ita ti on (of G re at Britain). T h e t he m e o f the C on fe ren ce will be M e a su r e m e n t o f O u t c o m e in R e hab il ita ti on. C o n t r ib u t i o n s will be welcome fro m all the professions co nc e rn ed with research in to the care of disabled people; docto rs , ph ysi ot her ap ist s, o c cu p a ti o n a l therapists, re ha bi lit at io n engineers, nurses, clinical psychologists, social w or ke rs etc. T he C o n fe ren ce will be held at the University o f E d in bu rg h an d a c c o m m o d a t i o n has been reserved for delegates a n d a c c o m p a n y i n g p e rso ns in the University’s Halls o f Residence. A full cu ltural a n d social p r o g r a m m e will be a r ra n g e d as well as visits to clinical facilities. T h e Co n fe ren ce lang ua ge will be English. Secretariat: C e nt re for Indust ri al C o n s u l t a n c y & Liaison University o f E d in bu rg h 16 Ge org e S qua re E d in b u r g h EH 8 9 L D Sc ot la nd , UK Tel: 031-667 1011 ext. 2369 Telex: 727442 ( U N 1 V E D G) 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. )