Name of Service: Children’s Physiotherapy Team Hounslow What our service does
The Children and Young Peoples Physiotherapy service is delivered by paediatric physiotherapists. These physiotherapists have specialist training in the assessment, management and treatment of neurodevelopmental, neuromuscular and childhood musculoskeletal conditions.
The Children and Young Peoples Physiotherapy team specialise in the treatment and management of children and young people 0-19 years, who have developmental difficulties or physical disabilities. This includes a wide range of conditions. Our goal is to enable these children and young people to reach their full potential for movement and to participate as fully as possible in family, school and wider social life.
The Children and Young Peoples Physiotherapy team specialise in treating children and young people 0-16 years, who have childhood musculoskeletal conditions. This is delivered through a clinic based service (Musculoskeletal Clinic / MSK Clinic) and includes a wide range of acute and sub-acute conditions.
The Children and Young Peoples Physiotherapy team provides (as part of the pathways involved in the care of children and young people with spasticity and variations in muscle tone) assessment for and provision of specialist orthotics devices. This includes (but is not limited to) the provision of Ankle Foot Orthoses (AFO’s), Orthopaedic footwear, and DEFO garments (Dynamic Elastomeric Fabric Orthoses).
Aims of service
To provide assessment, advice and treatment for all referred pathologies presenting a physical abnormality in age groups of 0-16yrs (or 0-19yrs if in a local authority specialist education).
• Increased GP engagement to ensure GPs are better informed of the referral criteria and in making referrals more appropriate • Increased engagement with social care workers, community nurses and health visitors to inform them on what is physiotherapy and what the service provides, which will improve referrals • To provide specific training to parents of children attending special schools on the importance of 24 hour postural management • To see children with cerebral palsy as early as possible as evidence suggests outcomes will be improved • When identified, to support the process of Transition from 19 to 25 years • Enable development and stability of the service through Professional training programmes such as Bobath, then deliver training, educate parents and carers and support staff which would be a cost effective approach.
1 MARCH 2016 • To be able to access equipment that offers the full scope of treatment in the professional practice of the Physiotherapy. A major requirement is the provision of a Treadmill in the Physiotherapy Gym - this would improve quality care to allow for optimal gait re-education, mobility rehabilitation, fitness training and weight loss.
Objectives
• To provide initial and on-going assessment to identify immediate physiotherapy intervention needs and early risk factors that could limit physical development in the future. This includes neurodevelopmental, neuromuscular and childhood musculoskeletal conditions as set out in the departmental criteria • To provide physiotherapy interventions in accordance with best practice and professional standards that results in improved physical movement
Where the service is located and the areas it covers
• Heart of Hounslow • Pre-schools • Local authority mainstream & special schools • Domiciliary settings
Paediatric Physiotherapy staff carries out various aspects of their role in a variety of locations throughout the borough. This includes patients’ usual place of residence, child and family centres, nurseries/private nurseries, mainstream schools/colleges and special schools. All clinic based work is undertaken at Heart of Hounslow Centre for Health.
The service is fully accessible to wheelchair users.
Who our service provides for
Our purpose is to provide a service to all children and young people of Hounslow who are referred with conditions which limit their physical ability.
The Physiotherapy Teams provisions are separated into 3 “streams” of provision: 1. Neurodevelopmental – Under 5’s 2. Neurodevelopmental – Over 5’s 3. Musculoskeletal
Children with neurodevelopmental, neuromuscular condition from the age of 0-19 can be referred into the service and children from the age of 0-16 with musculoskeletal conditions can be referred into the service.
The service accepts referrals from Health Care Professionals only.
2 MARCH 2016 Children must be registered with a Hounslow General Practioner (GP) and the following 3 Ealing GP practices (for which a cross commissioning agreement is in situ): • Dr Mangat, The Surgery, 3-5 Cecil Road, Hounslow. TW3 1NU • Dr Htoo, MWH Practice, 1 Vincent Road, Hounslow, TW4 7LH • Dr Sandhu, 48 Berkely Avenue, Cranford, TW4 6LA
Children with neurodevelopmental, neuromuscular condition from the age of 0-19 can be referred into the service and children from the age of 0-16 with musculoskeletal conditions can be referred into the service.
The criteria for acceptance of referrals are clearly defined in the referral criteria documentation.
Exclusion criteria
• Non Hounslow GP registered patients • No self-referrals accepted. • School staff seeking a referral for a child should request parents to seek referral from their GP • The exclusions criteria are also clearly stated in the referral criteria documentation.
How a child or young person can start using the service
The service accepts referrals from Health Care Professionals only.
Children must be registered with a Hounslow General Practioner (GP) and the following 3 Ealing GP practices (for which a cross commissioning agreement is in situ): • Dr Mangat, The Surgery, 3-5 Cecil Road, Hounslow. TW3 1NU • Dr Htoo, MWH Practice, 1 Vincent Road, Hounslow, TW4 7LH • Dr Sandhu, 48 Berkely Avenue, Cranford, TW4 6LA
Children with neurodevelopmental, neuromuscular condition from the age of 0-19 can be referred into the service and children from the age of 0-16 with musculoskeletal conditions can be referred into the service.
The criteria for acceptance of referrals are clearly defined in the referral criteria documentation.
Exclusion criteria
• Non Hounslow GP registered patients • No self-referrals accepted.
3 MARCH 2016 • School staff seeking a referral for a child should request parents to seek referral from their GP • The exclusions criteria are also clearly stated in the referral criteria documentation.
How decisions are made about eligibility for our service
The criteria for acceptance of referrals are clearly defined in the referral criteria documentation.
Referral Route • GP’s • Health visitors • Consultants • Therapists • Other health care professionals
How we communicate with service users and how they are involved in decision making/planning
The Provider will be required to support service users carers in understanding the practical aspects of their child’s individual needs, such support will be undertaken on both an ad hoc basis and as part of a wider care plan.
Supporting the self-care approach - the service will empower service users and carers with knowledge and confidence to use services in the community appropriately.
The service will provide information to the patient and carer at the initial appointment and at each change of service, in line with legal requirements and best practice: • Consent to treatment • Use of personal information • Community equipment – if necessary – training and written information • Self and carer management -at discharge if more appropriate
Our approach includes:
Direct Intervention: • Assessment, diagnosis, therapeutic intervention and management • Assessment, diagnosis and therapy intervention with other appropriate professionals in a multi-disciplinary setting • Development of individual self-management plans • Signposting to appropriate alternative providers/organisations • Therapeutic risk assessment • Neurodevelopment/ physiotherapeutic handling and exercise. • Provision of home, nursery and school exercise and activity programmes.
4 MARCH 2016 • Prescription/provision and monitoring of equipment and Orthoses to ensure proactive approach to postural management. • Prescription and monitoring of mobility equipment - this also includes working closely with Wheelchair and Special Seating services for wheelchair provision. • Group Classes • Consultation and advice with patients, carers and professionals via telephone, face to face whereby a professional report is discussed or the implementation of a care plan \ intervention or strategy is discussed
Indirect Intervention: • Preparation of materials for advice or therapeutic intervention • Training of carers, professionals and others as appropriate (As part of the package of care provided to the child and in order to support the delivery of that package of care) • Attendance at Case conferences – this may be classified as Direct Intervention if parent and or child is present • Preventative advice • Risk Assessment – Therapeutic risk assessment is carried out in line with professional Body Guidelines but schools and nurseries are responsible for manual handling.
Children will be discharged from the service
• If child is functioning within limits appropriate for them • If the child and their carers are able to self-manage their condition and continue with the therapeutic input with only regular assessments at pre agreed intervals • As a result of nonattendance in accordance with Provider service policy • Child or young person reaches 19 years of age - appropriate referral made to adult services for transition of care
How accessible our service is
The service accepts referrals from Health Care Professionals only.
Children must be registered with a Hounslow General Practioner (GP) and the following 3 Ealing GP practices (for which a cross commissioning agreement is in situ): • Dr Mangat, The Surgery, 3-5 Cecil Road, Hounslow. TW3 1NU • Dr Htoo, MWH Practice, 1 Vincent Road, Hounslow, TW4 7LH • Dr Sandhu, 48 Berkely Avenue, Cranford, TW4 6LA
Children with neurodevelopmental, neuromuscular condition from the age of 0-19 can be referred into the service and children from the age of 0-16 with musculoskeletal conditions can be referred into the service.
5 MARCH 2016
The criteria for acceptance of referrals are clearly defined in the referral criteria documentation.
Training our staff have had in supporting children and young people special educational needs and disabilities
Undergraduate degree in Physiotherapy Post Graduate certification in Paediatrics for example Bobath, Chailey etc Substantive rotation through wide and varied caseloads as student or junior therapist Internal supervision structures and clinical competencies Reflection and service development meetings
Who a service user should contact if they want to raise a concern or complain about something.
They should contact PALS
PALS, Complaints and Patient Experience
Thames House 180 High Street Teddington Middlesex TW 11 8HU 0208 973 3105 [email protected]
Who a parent carer/young person can contact for further information Stephen Ravenscroft Acting Hounslow Children’s Physiotherapy team lead Email: [email protected] Tel: 0208 973 3480
Name of person approving this information Stephen Ravenscroft Job title Acting Hounslow Children’s Physiotherapy team lead Email address [email protected]
6 MARCH 2016 HOUNSLOW REFERAL CRITERIA: UNDER 5’s - NEURO DEVELEOPMENTAL DIFFICULTIES
As per the referral form above, all referrals we require a full birth and developmental history and descriptions of muscle tone, functional difficulties, and any pain.
1.0 Developmental Delay The physiotherapy service will accept any referral for children with a described delay in all gross motor areas.
Details of the antenatal, birth history, gestational age at birth, prolonged hospital stay, premature, abnormal brain scan or any surgery in infancy is important to help guide the assessment process. Known genetic disorders must be disclosed as these children will often have a global developmental delay.
Exclusions: A referral is not necessary if the child is not sitting by 9 months, standing by 12 months or walking by 18 months as this is within normal variances. Only in the context of identified weakness, muscle tone (stiffness or floppiness), joint laxity or tightness or a concern about the child’s birth history or early development should a referral be sought.
2.0 Premature babies The physiotherapy service will accept referrals for all premature babies if they had abnormal MRI scans or any positive neurological indicators such as altered muscle tone, abnormal posturing-fisting of both hands and arching of back.
Exclusions: A referral is not necessary if the baby is meeting his/her developmental skills according to their corrected age (not actual age).
3.0 Cerebral Palsy/ Spina Bifida / Degenerative Brain disorders The physiotherapy service will accept referrals for children with Cerebral Palsy and other diagnosed neurological conditions.
4.0 Acute conditions The physiotherapy service will accept referrals for: • Leukaemia: To support children who have weakness / difficulty secondary to the chemotherapy. • Acute Neurological conditions such as Brain tumour , spinal tumours, Guillain Barre Syndrome, Meningitis
Exclusions: This service does not currently provide intervention for acute respiratory conditions in the community.
5.0 Down’s Syndrome The physiotherapy service will accept all the referrals for children with Down’s syndrome. These children are seen until they are competently walking and then
7 MARCH 2016 discharged unless they need any on-going orthotic foot wear or special seating provisions.
6.0 Hypermobility Syndrome The physiotherapy service will only accept referrals if this observation coexists with pain, weakness or a functional problem such as abnormal gait, pain, subluxing joints, dislocating joints, weakness, falls or developmental delay.
Exclusions: If the child is pain free and does not have any functional problems and is reaching their developmental milestones, physiotherapy is not indicated.
7.0 Developmental Coordination Disorder (Dyspraxia): The physiotherapy service would accept the referral and then provide these children with a block of therapy before discharging them again.
8.0 Frequent falls: The physiotherapy service will accept the referral if the child has an abnormal gait, joint laxity and/or changes in muscle tone (stiffness or floppy) or any concerns in the child’s birth or developmental history. This can be associated with Developmental Coordination Disorder (Dyspraxia).
Exclusions: A referral is not necessary for children under 2 years of age as the falling while learning to walk is a normal and expected feature of a child’s development.
9.0 Common Lower Limbs Postures and Anomalies
9.1 Tip Toe Walking The physiotherapy service would accept the referral if the child was over 16 months of age and if the toe walking is persistent, asymmetrical or there is associated delay (late rolling, sitting, crawling, pulling to stand), history of difficulties with birth, or prematurity, tightness of the calf muscles or the children or unable to squat keeping their heels on the floor. Toe walking can be associated with neuromuscular conditions, autism, neurological conditions, sensory issues and weakness.
Exclusions: Referral is usually not necessary if the child is under 16 months as toe walking is seen often in children when they are learning to weight bear and balance and if the toe walking is intermittent and the child is able to squat.
9.2 Knock Knees (Genu Valgum) This is a normal variant of lower limb posture in children aged 2-4 years old and usually resolves by 6 years old. Physiotherapy is not able to correct the condition in these cases.
In the following instance, please refer to an orthopaedic consultant.
8 MARCH 2016 • The child is over the age of 2 and there is a gap of more than 7cm between the ankles or • or a child of any age has pain
Exclusions: A referral is not necessary if the child is under the age of 2 years old and with no pain
9.3 Bow Legs This is a normal variant of lower limb posture in children aged 0-2 years old. Physiotherapy is not indicated and is not able to correct the condition in these cases.
Severe bowing requires investigations of Vitamin D levels, which should be sought via the GP and in the instance that the gap between the knees is more than 10 cm a referral to an orthopaedic consultant is indicated.
9.4 Flat Feet It is normal for babies and toddlers to have flat feet and this can persist until the age of 4 years old when the medial arches are fully developed.
The physiotherapy service would accept the referral if there was associated pain in the lower limbs, if the arch does not develop when the child stands on tip-toes, if there is stiffness in the foot or ligament laxity, or if the hind hoot (calcaneus) roll inwards (valgus).
Exclusions: In the absence of the above features, physiotherapy is not indicated for children under 4 years of age. Is it is normal for babies and toddlers to have flat feet as they need time to develop their arches and foot muscles.
9.5 In-toeing (Children’s feet pointing inwards) This is a common (and normal) variant of the normal lower limb posture seen in children under 5 years and is especially common in toddlers. It can be caused by tibial torsion, femoral anteversion, tight hamstrings and metatarsus varus.
It will usually resolve as the child grows and the musculo-skeletal system matures, normally by 10 years. Insoles and exercise will not correct this and a physiotherapy referral is not usually indicated. Children can be referred if over two years old, where they will be seen in the screening clinic for advice.
9.6 Out Toeing (Children’s feet point outwards) This is a normal posture seen in babies and toddlers, more often in children who have been born premature. It will resolve and does not usually require physiotherapy.
9 MARCH 2016 The physiotherapy service would accept referral if over the age of 14 months and associated pain, developmental delay (standing, walking), asymmetrical out-toeing or lax ligaments
Exclusions: In the absence of the associated conditions above, referrals will not be accepted.
10. Neuromuscular conditions The physiotherapy service would accept referrals for these conditions including • Muscular Dystrophy • Spinal Muscular Atrophy • Central Core Disease • Charcot Marie Tooth
11. Musculoskeletal conditions
11.1 Talipes Equino Varus/ Calcaneo Valgus The physiotherapy service would accept referrals for postural talipes.
Exclusions: • Fixed Talipes should be referred immediately to the Talipes Centre at the Chelsea and Westminster Hospital. • Children who have full range of movement need not be referred.
11.2 Torticollis The physiotherapy service would accept referral for Torticollis. These are often associated with developmental delay. (Plagiocephaly present as secondary to the Torticollis)
11.3 Plagiocephaly Physiotherapy is not indicated for Plagiocephaly. In the instance that it presents secondary to a torticollis or a developmental delay this should be referred as such. If the plagiocephaly is severe then it should be referred to the maxilla-facial consultant at Chelsea and Westminster Hospital.
11.4 Erbs Palsy The physiotherapy service would accept referral for Erbs Palsy.
11.5 Juvenile Chronic Arthritis The physiotherapy service would accept referrals for Juvenile Chronic Arthritis. Children with this condition will be prescribed exercise and advice.
10 MARCH 2016 HOUNSLOW REFERAL CRITERIA: OVER 5’s - NEURO DEVELEOPMENTAL DIFFICULTIES
As per the referral form above, all referrals we require a full birth and developmental history and descriptions of muscle tone, functional difficulties, and any pain.
1.0 Delayed / Impaired achievement of age appropriate gross motor Skills
Children’s gross motor skills should be assessed against age appropriate levels in order to assess if there is a deficit or difficulty. Please see the addendum which provides some guidance in respect of age appropriate gross motor skills.
The physiotherapy service will accept any referral with a described delay in their gross motor skills attainment.
Poor attainment of gross motor skills might be secondary to the following issues: • Abnormal gait patterns o This can be associated with Developmental Coordination Disorder (Dyspraxia). o Poor core stability o Muscle Weakness o Secondary to lower limb anomalies • Dyspraxia o The physiotherapy service would accept the referral and then provide these children with a block of therapy before discharging them again. • Poor Balance • Poor Core Stability and generalised weakness • Difficulties with co-ordination • Postural difficulties
2.0 Poor physical presentation and / or abnormal posture
The physiotherapy service will accept any referral where the following issues present:
2.1 Scoliosis / Spinal Curves 2.2 Asymmetrical Lying or standing Postures 2.3 Contractures and Deformities 2.4 Symptomatic Hypermobility 2.4.1 Exclusions: Where hypermobility is not associated with any pain or dysfunction (i.e. asymptomatic), there is no indication for physiotherapy provision.
3.0 Neurological issues
The physiotherapy service will accept referrals to attend to a number of areas where neurological concerns are identified: • Developmental regression – loss of gross motor and fine motor skills
11 MARCH 2016 • Increased or decreased muscle tone • Loss of muscle strength and onset of weakness • Frequent falls
4.0 Orthopaedic concerns
The physiotherapy service will accept referrals to attend to a number of areas where orthopaedic concerns are identified or support is required. Namely:
4.1 Casting or Botox. To help implement and ensure post-operative protocols are in place, such as strengthening and stretching
4.2 Surgery Pending / Recently completed. To help implement and ensure post-operative protocols are in place and to help facilitate a return to full function and ensure continued mobility
4.3 Common Lower Limbs Postures and Anomalies
4.3.1 Tip Toe Walking The physiotherapy service would accept the referral if: • toe walking is persistent, • asymmetrical • or there is associated difficulty in gross motor performance • Child unable to squat or stand with their heels on the floor • There is associated pain in the calf muscles or ankles
4.3.2 Knock Knees (Genu Valgum) This is a normal variant of lower limb posture in children aged 2-4 years old and usually resolves by 6 years old. If the presentation has not resolved by this time, physiotherapy is not able to correct the condition in these cases.
In the following instance, please refer to an orthopaedic consultant. • The child is over the age of 2 and there is a gap of more than 7cm between the ankles or • or a child of any age has pain
Exclusions: If not associated with functional difficulty or pain physiotherapy is not indicated.
4.3.3 Bow Legs
Physiotherapy is not indicated. A referral to an orthopaedic consultant is advised.
4.3.4 Flat Feet (Pes Planus)
12 MARCH 2016
The majority of flat feet are flexible and painless.
The physiotherapy service would accept the referral if: • there was associated pain in the lower limbs, • if the arch does not develop when the child stands on tip-toes, • if there is stiffness in the foot or ligament laxity, • or if the hind hoot (calcaneus) roll inwards (valgus).
Exclusions: Physiotherapy is not indicated if the child is pain free, has flexible flat feet and there is no reported / observed dysfunction
4.3.5 Pes Cavus Feet This is the opposite of flat feet and is when the arch of the foot is extremely pronounced. This is usually indicative of a neurological cause. Thus a referral to a paediatric neurologist or Paediatrician is best.
4.3.6 In-toeing (Children’s feet pointing inwards)
If this presentation is accompanied with gross motor difficulties, children can be referred where they will be seen in the screening clinic for advice.
Exclusions: This is a common (and normal) variant of the normal lower limb posture seen in children under 5 years and is especially common in toddlers. It can be caused by tibial torsion, femoral anteversion, tight hamstrings and metatarsus adductus.
Usually this twist will spontaneously resolve and naturally unwind itself as the child and the musculo-skeletal system matures, normally by 10 years. Insoles and exercise will not speed up this unwinding process and surgery is rarely ever required
A physiotherapy referral is therefore not usually indicated.
4.3.7 Out Toeing (Children’s feet point outwards)
If this presentation is accompanied with gross motor difficulties, children can be referred where they will be seen in the screening clinic for advice.
Exclusions: As with in-toeing, this condition will usually resolve spontaneously. A physiotherapy referral is therefore not usually indicated.
5.0 Other Conditions
13 MARCH 2016
5.1 Acute conditions
The physiotherapy service will accept referrals for: • Leukaemia: To support children who have weakness / difficulty secondary to the chemotherapy. • Acute Neurological conditions such as Brain tumour , spinal tumours, Guillain-Barre Syndrome, Spinal Muscular Atrophy (SMA), Meningitis • Post-operative interventions • Rehabilitation following Fractures -
Exclusions: This service does not currently provide intervention for acute respiratory conditions in the community. . 5.2 Neuromuscular conditions
The physiotherapy service would accept referrals for these conditions including: • Muscular Dystrophy • Spinal Muscular Atrophy • Central Core Disease • Charcot Marie Tooth
5.3 Cerebral Palsy/ Spina Bifida / Degenerative Brain disorders
The physiotherapy service will accept referrals for children with Cerebral Palsy and other diagnosed neurological conditions.
5.4 Down’s Syndrome
The physiotherapy department will only see these children for on-going orthotic foot wear or special seating provisions at home or in school or for those children not yet walking.
Direct physiotherapy treatment sessions are not indicated.
14 MARCH 2016 HOUNSLOW REFERAL CRITERIA: PAEDIATRIC MUSCULOSKELETAL (MSK) CONDITIONS
There are a number of conditions which can be referred to the Paediatric Physiotherapy team for assessment by our MSK specialists:
1.0 Spinal Conditions:
1.1 Back Pain: Both neck and back pain can occur in childhood. Physiotherapy provides postural and ergonomic advice, especially re carrying school bags and the like. Home exercise programmes for strengthening trunk muscles and stretches to regain flexibility are provided.
Children with back pain should be encouraged to stay active, within the limitations of their pain, as inactivity worsens pain and stiffness. The following treatments can be useful in older children: localised spinal manipulation, deep tissue/trigger point massage, K-taping
1.2 Ribs Intercostal muscle strains can occur, and these respond well to stretching exercises
1.3 Scoliosis: Children with pain due to scoliosis can be referred for physiotherapy. Postural and spinal mobilising exercises can reduce pain. The physiotherapist liaises with the Orthopaedic Consultant as required.
1.4 Scheuermanns Disease: This is an increase in thoracic kyphosis that can occur during growth. Physiotherapy aims at postural correction if pain is present.
Exclusions: Many cases of Scheuermanns are asymptomatic and do not require physiotherapy if there is no pain.
1.5 Torticollis and/or Neck Pain: Any physiotherapy referrals for neck pain will be prioritised for management of pain and loss of movement with referral to orthopaedics if indicated.
2.0 Lower Limb Conditions:
2.1 Hip Dysplasia: Any concerns regarding hip stability should be referred directly to orthopaedics at WMUH. Only after having been seen by the orthopaedic consultant should a referral then be made to the MSK department should physiotherapy be indicated.
2.2 Perthes Disease:
15 MARCH 2016 This is a condition of degeneration of the hip joint and is characterised by loss of hip movement, pain and limping. Children with perthes are always seen by an orthopaedic consultant. Physiotherapy aims to maintain/improve hip range of movement and improve walking. Children with perthes can benefit from hydrotherapy.
2.3 Knee Pain: Knee pain in adolescents is common due the effects of growth on the knee joint or injuries. Children usually benefit from a home programme of quadriceps strengthening and hamstring stretching.
2.4 Osgood Schlatters: Tenderness of the tibial tuberosity is common in active children and affects boys more than girls. This is a self-limiting condition that will resolve with time. Physiotherapy advises hamstring and quadriceps stretches, which research demonstrates are very effective in providing symptom relief. Children with recurrent episodes of Osgood Schlatters can benefit from use of ice for relief of pain associated with inflammation. Some children gain relief of their symptoms using a patellar strap whilst playing sports. Strengthening the quadriceps is contraindicated whilst there is inflammation around the tibial tuberosity but a child should be advised to continue activities and sports within the limits of their pain.
2.5 Bow Legs This is a normal variant of lower limb posture in children aged 0-2. Physiotherapy is not indicated and is not able to correct the condition in these cases.
Severe bowing requires investigations of Vitamin D levels, which should be sought via the GP and in the instance that the gap between the knees is more than 10 cm a referral to an orthopaedic consultant is indicated.
2.6 Flat Feet: The majority of flat feet are flexible and painless.
The physiotherapy service would accept the referral if: • there was associated pain in the lower limbs, • if the arch does not develop when the child stands on tip-toes, • if there is stiffness in the foot or ligament laxity, or if the hind foot (calcaneus) roll inwards (valgus).
Onward referral to a podiatrist / orthotist may be indicated.
Exclusions: Physiotherapy is not indicated if the child is pain-free, has flexible flat feet and there is no reported / observed dysfunction.
2.7 Severs Disease: Heel pain in children can be resolved with stretches, exercise, K-taping and/or orthotics.
16 MARCH 2016
2.8 Pes Cavus Feet This is the opposite of flat feet and is when the arch of the foot is extremely pronounced. This is usually indicative of a neurological cause. Thus a referral to a paediatric neurologist or paediatrician is best.
2.9 In-toeing (Children’s feet pointing inwards) If this presentation is accompanied with gross motor difficulties, children can be referred where they will be seen in the screening clinic for advice.
Exclusions: A physiotherapy referral is not usually indicated. This is a common (and normal) variant of the normal lower limb posture seen in children under 5 years and is especially common in toddlers. It can be caused by tibial torsion, femoral anteversion, tight hamstrings and metatarsus adductus. Usually this twist will spontaneously resolve and naturally unwind itself as the child and the musculoskeletal system matures, normally by age 10. Insoles and exercise will not speed up this unwinding process and surgery is rarely required.
3.0 Upper Limb conditions 3.1 Shoulder Pathology Although less common in the paediatric cohort, tendinopathies/overuse/trauma injuries can occur in teenagers, and physiotherapy intervention is indicated. 3.2 Elbow Adolescents sometimes suffer from elbow tendinopathies, such as tennis elbow, which respond well to physiotherapy exercises. Sometimes there is stiffness and loss of ROM related to previous elbow trauma, which physiotherapy can help to improve.
4.0 Fractures: Most children who have recently come out of plaster casts do not require physiotherapy. Referrals are accepted for children who are slow to regain joint range of movement or whose fracture has caused a functional limitation (for example if not using their arm or slow to wean from crutches).
5.0 Soft Tissue Injuries / Sports injuries: Sprains and strains will be prioritised for physiotherapy treatment.
6.0 Juvenile Arthritis: The children’s physiotherapists will see children with inflamed joints, often in association with a consultant paediatrician. Children with arthritis can be provided with exercise programmes, advice and/or hydrotherapy.
7.0 Torticollis The physiotherapy service would accept referral for torticollis. These are often associated with developmental delay. (Plagiocephaly may be present, secondary to the torticollis).
8.0 Talipes Equino Varus/ Calcaneo Valgus
17 MARCH 2016 The physiotherapy service would accept referrals for postural talipes. Positional talipes and metatarsus adductus (inward pointing forefoot) caused by intrauterine moulding are commonly referred by midwives but can be referred by health visitors or GPs if the foot deformity is slow to resolve.
Exclusions: • Fixed Talipes should be referred immediately to the Talipes Centre at the Chelsea and Westminster Hospital. • Children who have full range of movement need not be referred.
9.0 Plagiocephaly Physiotherapy is not indicated for plagiocephaly. Where it presents secondary to a torticollis or a developmental delay this should be referred as such. Severe plagiocephaly should be referred to the maxilla-facial consultant at Chelsea and Westminster Hospital 10.0 Erbs Palsy The physiotherapy service would accept referral for Erbs Palsy.
11.0 Hypermobility Syndrome The physiotherapy service will only accept referrals if this observation is supported with their having a functional problem such as abnormal gait, pain, subluxing joints, dislocating joints, weakness or developmental delay.
Exclusions: If the child is pain free and does not have any functional problems and is reaching their developmental milestones, physiotherapy is not indicated.
18 MARCH 2016
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