Best Practices in PT Management
Summary of the Condition: Legg-Calve-Perthes Disease (LCPD) is a rare pediatric disorder causing avascular necrosis of the hip and results in the following impairments: range of motion, strength, pain, balance, and gait.
Guide to PT Practice – Practice Pattern and Suggested Management
Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction. http://guidetoptpractice.apta.org/content/1/SEC11.body. According to the Guide, 3 – 36 sessions are the range of sessions for 80% of patients falling under this category to achieve their goals and expected outcomes. The manual therapy techniques suggested for this general population are manual traction, connective tissue and therapeutic massage, and peripheral joint mobilization. Please note this is not specifically suggested for patients with LCPD. According to the Guide, the suggested electrotherapeutic modalities include biofeedback and electric stimulation such as, electrical muscle stimulation (EMS), neuromuscular electrical stimulation (NMES), and transcutaneous electrical nerve stimulation (TENS).
The Cincinnati Children’s Hospital has developed an evidence-based clinical care guideline for the conservative management of LCPD1. Below is a summary of the recommended interventions. Please CLICK HERE for more detailed information on the protocol.
The main goals of conservative management of LCPD are to promote and optimize range of motion, strength, and joint preservation to minimize impairments and maximize function. Containment of the femoral head in the acetabulum is the most important focus during each stage of LCPD.
Relieving Pain
• Hot Pack for pain management with stretching2
• Cryotherapy for 20min at a time2
Increasing Strength
• Hip abductors
• Hip flexors
• Hip extensors
• Hip internal & external rotators
• Gluteus medius
**Avoid single limb stance activities due to increased force through hip joint during severe involvement stage
Improving Range of Motion
**ROM is typically lost in this population due to muscle guarding secondary to pain from incongruent joint surfaces
• Static Stretching of LE musculature
• Dynamic ROM and AAROM for muscle guarding due to pain and if unable to achieve through static stretching
• AROM & AAROM following passive stretching to maintain newly gained ROM
• Stretching should include the following muscle groups: hip internal and external rotators, hip abductors, hip extensors, and any other LE motion that is significantly limited.
Functional Activities
• Single leg dynamic function activities such as side steps and step ups, according to WB status and involvement phase
Home Exercise/Modality Use
• Cryotherapy for 20min at a time may be used to decrease pain and inflammation
• The HEP should be based on orthopedist recommendations due to the staging of the disease, age of onset of the disease, radiographic data, and patient presentation
Post-Surgical Physical Therapy - There is no evidence on the best post-op physical therapy interventions following femoral osteotomy in children with LCPD
• The child will most likely be non-weight bearing approximately 6-8 weeks3
• During the non-weight bearing phase AROM of the joints above and below the surgical site should be done to prevent stiffness and undue weakness3
• Once the cast is removed, AAROM, AROM, and resistive exercises should be done to restore strength lost from immobility3
• Static stretches held for 30 sec+ and contract-relax stretches should be done every day followed by AROM exercises to restore and maintain full ROM
References
1. Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for conservative management of Legg-Calve-Perthes disease in children aged 3 to 12 years. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2010 Oct. 16 p. [47 references]
CLICK HERE for the PROTOCOL
2. Nadler, S.F.; Weingand, K.; and Kruse, R.J.: The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain Physician, 7(3):395-9, 2004
3. Kisner C., Colby L.A. Therapeutic Exercise: Foundations and Techniques. 5th ed. Philadelphia, PA: F.A. Davis Company; 2007.
