Physical Therapy

Physical Therapy


Pain Management, Strength, Range of Motion

In the early stages recommendations will likely include activity restriction including restriction on weight bearing activities. It’s important for the healing process to stay active. Adapting to hip-safe activities such as swimming as well as specific exercises recommended by the medical-surgical team, including a physical therapist, maintain strength, preserve range of motion, and have been linked to pain reduction and positive treatment outcomes.

An Interdisciplinary Approach

A physical therapist (PT) works with a multidisciplinary healthcare team to get your child the equipment he or she needs to stay active, learn to use that equipment, and strengthen muscles in the process.

A PT may be involved in ordering a wheelchair, walker, crutches, and other adaptive equipment. A PT may instruct your child in using this equipment; it takes some getting used to and even works new and different muscle groups. Working with the orthopedic surgeon, a physical therapist will recommend exercises to strengthen muscles and maintain or increase range of motion. These protocols, like Perthes, are specific and tailored to your child and take into consideration specifics of treatment such as “conservative management” or “post-op.”

Weight Bearing Status

Due to the age at onset of Perthes disease, it can be a challenge to get an active child to understand he or she must “take it easy” especially during periods without pain. Furthermore, being told to give up a favorite hobby or sport can impact your child’s mood in a big way. Still, weight bearing restriction remains a cornerstone of conservative treatment, and it’s not as simple as your might think. Here’s the scoop on the many levels of weight bearing.

  • NWB – no weight on the leg which has the Perthes
  • PWB – partial weight bearing
  • TTWB – toe touch weight on side with Perthes – toes only on ground, uses assistive device to “unload” weight
  • FFWB – foot flat weight on side with Perthes – places entire foot on ground, but uses assistive device to “unload” weight
  • % of body weight (ie.  20% of 50# = 10# – practice on bathroom scales)
  • WBAT – weight bearing as tolerated – weight on the leg which has the Perthes – with or without devices


Exercises may be categorized into levels, with specific goals and precautions for each. These exercises are some examples of what may be recommended by your medical-surgical team. It’s important to note Legg Calve Perthes Foundation offers this information as representative information only and recommends following the treatment guidelines set forth by your child’s specific team.

 

Level 1


Goals
  • Contain hip by maintaining 25 degrees or more of hip ABD (abduction, or legs spread from midline).
  • Protect from excessive hip joint forces
  • Remodel contained femoral head with low load / high repetition exercise
Precautions
  • NWB / TTWB / FFWB
  • WBAT in brace or cast for transfers and supervised HEP (home exercise program)
  • NO SLR (straight leg raise),  HIP HYPEREXTENSION, ABD AGAINST GRAVITY

 

Mobility
  • Crutches in home
  • Wheelchair at school / long distances
  • NWB / TTWB / FFWB
  • WBAT in brace or Petrie cast for transfers and supervised HEP
  • A-FRAME BRACE:    23 hours / day
Recreational
  • Handcycling
  • Pushing self in w/c – road racing in w/c
  • Swimming (if 25+ degrees of hip ABD)
  • UE weight-lifting
  • Kayak, canoe, rowing
  • Bowling from w/c
  • Playing catch / disc golf from w/c
  • Archery – seated
  • Wii sports – seated
  • Ping pong – seated
Remodeling; Supervised
  • Stationary bike – no resistance, no pushing with affected LE  (individual basis)
  • Standing closed chain circumduction in brace or cast (hula hoop maneuver)
  • w/c – wheelchair
  • UE – upper extremity – arm
  • LE – upper extremity – leg

Level 2


Goals
  • Contain hip by maintaining 25+ degrees of hip ABD
  • Protect hip from excessive forces
  • Remodel contained femoral head with low load / high repetition exercises
Precautions
  • NO  STRAIGHT  LEG  RAISES
  • NO  HIP  HYPEREXTENSION
  • NO  HIP  ABD  AGAINST  GRAVITY

 

Mobility
  • Crutches in home – weight bearing may change
  • Wheelchair long distances / at school
  • A – FRAME  BRACE:  12 HOURS PER DAY


Recreational
  • Handcycling
  • Pushing self in w/c – road racing in w/c
  • Swimming (if 25+ degrees of hip ABD)
  • UE weight-lifting
  • Kayak, canoe, rowing
  • Bowling from w/c
  • Playing catch / disc golf from w/c
  • Archery – seated
  • Wii sports – seated
  • Ping pong – seated
Remodeling; Supervised
  • Stationary bike – no resistance, no pushing with affected LE  (individual basis)
  • Standing closed chain circumduction in brace or cast (hula hoop maneuver)

Level 3


Goals
  • Contain hip by maintaining 25+ degrees of hip ABD
  • Protect hip from excessive forces
  • Remodel contained femoral head with low load / high repetition exercise
  • Early strengthening of hip ABD, EXT, and ER with a short lever arm
  • EXT – extension (move backward)
  • ER – twists leg outward at the hip
Precautions
  • Partial WB – 50% body weight for supervised exercises with hip in ABD position
  • WBAT for up to 10 feet on an individual basis  (with AD)
  • NO STRAIGHT  LEG  RAISES
  • AD – assistive device (ie walker of crutches)

 

Mobility
  • Crutches for PWB – 50% body weight or WBAT – if allowed for 10 feet
  • Decrease wheelchair use
  • Brace: (hours to wear)


Recreational
  • Handcycling
  • Pushing self in w/c – road racing in w/c
  • Swimming (if 25+ degrees of hip ABD)
  • UE weight-lifting
  • Kayak, canoe, rowing
  • Bowling from w/c
  • Playing catch / disc golf from w/c
  • Archery – seated
  • Wii sports – seated
  • Ping pong – seated
Remodeling; Supervised
  • Stationary bike – no resistance, no pushing with affected LE  (individual basis)
  • Standing closed chain circumduction in brace or cast (hula hoop maneuver)

Level 4


Goals
  • Advanced strengthening of hip ABD, EXT, ER
  • Avoid hip / knee collapse with single leg loading
Precautions
  • WBAT

 

Mobility
  • Crutches  PRN (as needed)
  • Brace:   (hours to wear)



Recreational

Once cleared by the doctor, can resume activities however you may want to consider low vs high impact activities and may consider avoiding contact sports such as football.


Sample HEP and Image credit: Perthes Parent Conference, Texas Scottish Rite Hospital for Children, 2017.