Working With Kids: Physical Therapy and the Pediatric Athlete

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Working With Kids: Physical Therapy and the Pediatric Athlete

By Michele Wojciechowski

PT Magazine - March 2007

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Working with pediatric patients poses one set of challenges. Working

with athletes presents a second set of issues. When PTs deal with

patients at the intersection of those two populations-pediatric

athletes-they may feel they're in unfamiliar territory. Here's some

advice and guidance from the field.

" Pediatric sports physical therapy is kind of a new animal, " says

Mark Paterno, PT, MSPT, MBA, SCS, ATC, coordinator of orthopedic and

sports physical therapy at the Sports Medicine Biodynamic Center at

Cincinnati Children's Hospital Medical Center. " It is not something

that has been prominent for years. "

Contributing to the new dynamic is its special niche, which requires

knowledge of both pediatrics and sports medicine. Another

contributor is the rise in the number of pediatric athletes. A study

by the Centers for Disease Control and Prevention (CDC) estimates

that high school sports participation has grown from 4 million

during the 1971-1972 school year to 7.2 million in 2005-2006.1 That

same study found that high school athletes account for an estimated

2 million injuries, 500,000 doctor visits, and 30,000

hospitalizations annually.

Pediatric Athletes in Brief

Approximately 38% of children aged 9-13 participate in a physical

activity with an organized group that has a coach, instructor, or

leader.1

An estimated 7.2 million high school students participated in high

school sports in 2005-2006. They experienced an estimated 2 million

injuries, 500,000 doctor visits, and 30,000 hospitalizations.2

In a study of nine high school sports-baseball, football, and

wrestling (boys); softball and volleyball (girls); and basketball

and soccer (boys and girls)-the overall injury rate was 2.44 per

1,000 athlete exposures. In each sport, the injury rate was higher

in competition than in practice.2

High school baseball players are most likely to experience

forearm/wrist/hand injuries (24.6% of total injuries), according to

one study. The most common basketball injury is to the ankle or foot

(39.3% in boys, 36.4% in girls). The most common football injury is

to the hip/thigh/leg (16.7), and the most common wrestling injury is

to the shoulder/arm (18.4%).3

Most high school sports injuries-about 90%, with little variation by

sport-are new injuries, rather than reinjuries.3

References

1 Physical activity levels among children aged 9-13 years-United

States, 2002. Centers for Disease Control and Prevention. MMWR

Weekly. Aug 22, 2003;52(33):785-788. Available at

www.cdc.gov/mmwR/preview / mmwrhtml/mm5233a1.htm . Accessed January

3, 2007.

2 Sports-related injuries among high school athletes-United States,

2005-06 school year. Centers for Disease Control and Prevention.

MMWR Weekly. Sept 29, 2006;55(38):1037-1040. Available at

www.cdc.gov/ mmwR/preview/mmwrhtml/mm5538a1.htm . Accessed January

3, 2007.

3 J, Barber-Foss K. Injury patterns in selected high school

sports: a review of the 1995-1997 seasons. Journal of Athletic

Training. 1999;34(3):277-284.

As children become involved in sports at younger and younger ages,

and as more elite child athletes emerge, typically from ages 8

through 16, the field of physical therapy for the pediatric athlete

continues to grow.

Dealing with and treating child clients is much different from

dealing with adults-not only because of the adolescents' physical

immaturity, but also because of their emotional and psychological

needs, say PTs whose patients include pediatric athletes.

One recent journal editorial put it this way: " The pediatric athlete

is at risk for injury…the etiology and treatment of pediatric

injuries differs from adult athletes, and…there are black holes

within our knowledge of how to deal with these problems. " 2 But a

growing number of physical therapists (PTs) are conducting

researching and treating this segment of the population.

Children Aren't Little Adults

" We can't treat children like young adults, " explains Paterno,

because, quite simply, they are not adults. PTs dealing with this

population need to manage the care of children by taking into

consideration the way their bodies heal and the way in which they

sustain their injuries, Paterno explains. " We need to keep in mind

their psychosocial development as well. When you talk to a 10-year-

old about his or her injury, it is much different from talking with

an 18-, 20-, or 30-year-old. "

Paterno began his career working with an adult population. Having

seen the full spectrum of clients, he urges his PTs to be cautious

when implementing exercise with pediatric athletes, always keeping

in mind possible long-term implications. He makes sure that they are

protecting their joints and that they are not engaging in activities

that could lead to early breakdown of cartilage later in their lives.

" Many times with adults, there are warning signs that exercises we

do may be problematic to their cartilage. They have pain. They have

grinding in their joints, " explains Paterno. " Whereas in these young

kids, many times they don't. They may not feel a lot of pain. They

may not feel as if they have as many limitations. If someone has an

injury to their cartilage, we need to be cognizant of that and

protect them early on-even though the patient may be raring to go. "

Paterno sees this especially with high school athletes who want to

play regardless of their injuries. They may insist they aren't

hurting when they are. So it's often up to the PT to counsel them

about the possible long-term effects if they play with an injury.

Miles, PT MEd, PCS, owner of Miles & Associates, a

private practice in Whitehall, Pennsylvania, and chair of APTA's

Pediatric Sports-Fitness Special Interest Group, says that it's

important for PTs not only to know that they can't treat children

like adults, but also to understand why.

" The PT must understand musculoskeletal and physiological

development as well as growth patterns, " says Miles. " All therapists

treating children must be aware of developmental biomechanics to

best serve their clients. "

She explains that cardiovascular and musculoskeletal systems of

children are very different from those of adults. " Developmental

biomechanics is an evolving process through adolescence, and PTs

must understand the process, " Miles says.

Miles' practice is limited to pediatric clients, 95% of whom have a

development disability. " I believe that therapists who treat

children, whether they are diagnosed with a chronic development

disability or they are highly skilled athletes, must hone their

skills for particular age groups. "

No Two Children Are Alike

Because their bodies are at different stages of development, even

children within the same age group can have different responses to

injuries, says Paterno. " We find that children develop at different

ages. Some of the research that we do in our lab looks at

differences that occur through puberty, " states Paterno. " We find

that if we try to classify by age, we get very different results

than if we categorize by pubertal status. What that tells us is even

though we have an interest in their ages, it is important for us

that we look at how physically developed they are.

" Before they reach puberty, many times their bones are much weaker

than some of their ligaments and other structures, " explains

Paterno. " Whereas in adults, the bones are much stronger, and our

ligaments are a weak link. "

For example, says Paterno, a hit on the side of an adult's knee

could result in a medial collateral ligament injury. If the same

injury occurs to a child, it could cause a fracture or growth plate

damage. As children grow and hit puberty, their injuries may more

mimic those of adults. But until that happens, PTs have to be aware

of each child's physical maturation status as well as their age as

they consider the injury and determine treatment.

No More " Off Season "

The field of physical therapy for the pediatric athlete has changed

greatly in recent years. Why? When children played different sports

throughout the year, they would use different body parts and

movements. Or, they would play in one sport and then have an off

season. As a result, they didn't tend to keep repeating the same

injuries.

Today, however, children, especially elite athletes, can play one

sport all year long. Sandy Quillen, PT, PhD, SCS, FACSM, associate

dean of the College of Medicine and director of the School of

Physical Therapy & Rehabilitation Sciences at the University of

South Florida, points to gymnastics, which long has been a year-

round sport. " There is a high frequency of injury in female

gymnasts. They place incredible demands on their bodies. They are in

the gym all the time, " says Quillen. Breaking up the injury cycle

for these girls is challenging because there are fierce competitors.

" Some of the injuries carry with them long-term consequences that we

only now are beginning to appreciate, " says Quillen.

Other sports are emerging in the same patterns because kids can play

in club sports and travel teams year-round and attend camps during

the summer as well as winter and spring breaks-and playing at these

elite levels puts them at risk for overuse injuries. Says

Paterno, " That is a very different dynamic from playing different

sports through different seasons throughout the year. "

Overuse injuries also are coming from the attitude of " win at all

costs, and try to work through your injuries, " says Paterno.

Regarding some sports groups, Quillen says, " It is not play anymore.

It is work. "

McHorse, PT, SCS, Cert MDT, head physical therapist at Central

Texas Pediatric Orthopedics, a private practice in Austin, Texas,

says that among the highly athletic children and adolescents he

sees, 90% of the injuries result from overuse. " You see with a lot

of these kids that there is not even a break between seasons. They

finish fall baseball and 3 days later start winter baseball, then

spring baseball, " says McHorse. " So we see lots of overuse injuries

that with a little bit of rest and a little bit of prevention could

be avoided. "

When asked how these overuse injuries may affect children as adults,

McHorse admits, " It concerns me because none of us knows. I worry

that when they are 35 to 45, they are going to have a much earlier

onset of certain conditions in the knees and shoulders. We are

seeing that now. We see injuries in 13-year-olds that used to happen

to 17- and 18-year-olds. That is something we need to pay attention

to. "

Paterno echoes McHorse's concerns, adding, " The question that

researchers and clinicians alike are trying to answer is: Is this

because of a focus on sports specialization? Some research is

starting to look into that, but there are no definitive answers yet.

We are starting to see adult injuries in younger populations. There

is not a lot of evidence to validate it now. However, it is the

prevailing thought that that is the case. "

Knowing that many of the pediatric athletes they see will have

particular types of injuries, part of the PT's role is to implement

interventions to help prevent re-injury. Miles says, for example,

that if a PT is working with a young female who may be prone to ACL

injuries, the PT should provide her with a prevention program. The

PT might instruct the young athlete and/or her coach in proper

postural alignment, proper strengthening techniques, appropriate

jumping techniques, and proper mechanics for the sport she plays.

Other Roles for the PT

In addition to talking with individual patients, PTs also can reach

out to the community. McHorse gives injury prevention lectures at

schools and many different sports clubs, to both children and

adults. " If I am going to talk about actual prevention exercises, I

like to have the kids there, too, so we can practice them, " he says.

The PT's Role: Beyond Injuries

The role of the PT can extend beyond injury prevention and

management. In " The Female Athlete Triad: An Emerging Role for

Physical Therapy, " a E Papanek, PT, MPT, PhD, ATC, FASM,

described the female athlete and the key role physical therapists

(PTs) may play.1

The triad involves the coexistence of three distinct medical

conditions that may occur in athletic girls and women. It includes

eating disorders/disordered eating behavior,

amenorrhea/oligomenorrhea, and decreased bone mineral density

(osteoporosis and osteopenia). When coupled with inadequate

nutrition, the high caloric expenditure of exercise training results

in a sustained negative caloric balance or low energy availability,

which is sensed by the hypothalamus, initiating a neuroendocrine

adaptive cascade.

Papanek, associate professor, department of physical therapy, and

director of exercise science at Marquette University, writes, " In

general, orthopaedic and sports-related injuries make up a large

portion of a physical therapist's outpatient practice. Physical

therapists may have access to an entire team and typically can spend

more time with patients than other clinicians involved in their

care. For this reason, the profession is especially suited for

detecting the female triad and intervening. " 1

Intervention for the female athlete triad consists of a physician,

nutritionist, psychologist, exercise physiologist or appropriately

trained physical therapist, athletic trainer, and, in terms of

providing support and structure for the program, the coach or

parent. Papanek writes, " The physical therapist and exercise

physiologist are the only team members with expertise in exercise

metabolism, training adaptations, sports biomechanics, and exercise

prescriptions. Furthermore, the physical therapist brings additional

expertise in the assessment and intervention of athletic and

orthopaedic injuries. This expertise makes the physical therapist an

integral part of any interdisciplinary team. "

Reference

1 Papanek, P. J Orthop Sports Phys Ther. 2003;33:594-614.

Another role for PTs, Miles says, is participation in pre-season

screenings for sports teams to make sure that the children are ready

to play.

PTs also sometimes are involved in fitness programs. With the

obesity epidemic today, the PTs interviewed for this article say,

fitness for children is a must. Miles says that her practice offers

a fitness program, which she says is especially important for the

population she serves since most of those children have physical

disabilities and many may not be able to be involved in a team or

individualized sports.

Fitness programs also are offered for the siblings of children who

are receiving physical therapy. While one child receives physical

therapy, the other can participate in a separate individualized

fitness program. The program encourages children of similar ages to

participate in the fitness programs together. " We make it more

interactive for everybody, " she says. " It just becomes fun. "

As chair of the SIG, Miles says that she spends a few hours each

week answering questions from PTs about fitness or obesity-related

programs. McHorse often recommends fitness programs before he

discharges patients if they are either inactive or obese.

Motivation and Advocacy

Working with kids presents another challenge for PTs. Sometimes they

have to act not only as physical therapists, but also as motivators

and advocates for the children.

" The number one challenge to be successful in this field is to

connect with the kids and get them to do what you are asking them to

do, " says McHorse. " Everything I do is very home-exercise based. One

of the challenges these days is that school is very competitive,

even elementary school. It is very difficult to get a parent to pull

a child out of school for physical therapy, so we try to keep

therapy visits in the office to once a week. But if you're going to

do that, you have to be able to motivate them to do exercises at

home every day. Otherwise, they aren't going to get better. "

While working with some children, PTs are part of a team, says

Paterno. " Many times, with adults, you are just dealing with that

adult, addressing their needs and goals. But for an adolescent

athlete and a pediatric athlete, you are dealing with the child's

goals, the family's goals, the family dynamics, how it is affecting

their team and their coach, and making sure that not only from a

health care side, but also that all the members of the family who

are going to be affected by the decisions made are informed and feel

part of that process as well. "

But PTs also have to balance how much the child does at home. Some

children, because of pressure to perform in sports from either

coaches or parents, will push too hard too fast and must be, in

essence, reined in. If the child is under too much pressure, the PT

may have to act as an advocate.

Quillen recalls that when he lived in Indiana, PTs often convinced

youth baseball coaches to take the American Red Cross Sports Safety

Course so that they could learn rudimentary first aid. During one

subsequent game, a child slid into second base and broke his ankle.

The coaches knew what to do and what not to do. They said they were

glad they had followed the PTs' advice and taken the class. Over

time, Quillen reports, the PTs gained more credibility and then

could speak to parents about their children-telling them that

sometimes the reason their children were getting hurt was because

they were being pushed too hard and needed a break.

" You become a trusted resource and counselor, " says Quillen.

Taking into consideration how an injury will affect a child or teen

development is important. Helgeson, PT, DHSc, SCS, assistant

professor in the physical therapy department at Idaho State

University, has worked as a pediatric athlete clinician and is

involved on the board of directors of a baseball league, consulting

with them on safety and similar issues.

" My philosophy is that the usual pediatric athlete faces so many

developmental issues. You really need to treat that young person

first as an individual and take into consideration his or her own

emotional and social development-being very aware of that young

person's current state in consideration of who they are living with,

their environment and what the role of sports is in their lives, "

says Helgeson. " For each kid, what sports means can be very

different. For some, it's what their dads want them to do. For

others, this is their outlet to get away from family situations for

a few hours a day. For others, they already have dreams of becoming

a professional athlete. So you have to tailor your feedback and your

impact on that individual based on where that child is coming from. "

Also, he says, a young person's injury may affect his or her life in

a way that it wouldn't an adult's. For example, if the child goes

back to school on crutches, it might make him or her a target for

harassment. So it's important, Helgeson says, to know how an injury

may affect other phases of the child's life.

Learning the Skills

When asked if particular training is needed to work with pediatric

athletes, McHorse says, " There really isn't any kind of special

training. That's one of the things I discovered when I came out of

physical therapy school. " He knew he wanted to work with pediatric

athletes, but couldn't find many continuing education courses in

pediatric sports medicine. So he read a lot on the subject. As time

passed, and he became more of an expert in the field, he eventually

began teaching courses on it and giving talks, as did Paterno.

" You end up becoming an expert on it because it is what you do all

day, " says McHorse. He has given lectures on the subject for

everyone from state associations to local groups. He even has

developed a 2-day continuing education program.

McHorse would like to see more PT students pursuing pediatric sports

physical therapy and even makes them an offer: " If students are more

interested in that, then they can rotate through on one of their

clinical affiliations through me. "

Miles says that students who now are in PT school are receiving more

training in this area than she and her peers did. A couple of years

ago, she and Paterno spoke in Pennsylvania about the topic during a

weekend conference; the first day was related to the pediatric

athlete while the second concentrated on athletes with disabilities.

Looking to the Future

" I think the future is bright for pediatric sports physical therapy

for many reasons, " says Paterno. " This idea that young kids have

adult-type injuries, but we can't treat them like adults-it begs a

need for us to become more skilled in managing those. I think I can

put my researcher hat on and say that is something that we need to

do a better job of-designing the best clinical pathways and the best

care guidelines for these younger athletes.

" Many times across medicine, whether it's a special test or rehab

protocols or rehab designs, they are designed for adults. Many

times, we just try to use the adult model for young children, and it

doesn't always work considering their special needs as far as a

growing, developing body and their psychosocial needs. From that

standpoint, there is endless potential. "

__________________

Michele Wojciechowski is an award-winning freelance writer in

Baltimore, land, and a frequent contributor to PT Magazine.

References

1 Sports-related injuries among high school athletes-United States,

2005-06 school year. Centers for Disease Control and Prevention.

MMWR Weekly. Sept 29, 2006;55(38):1037-1040. Available at

www.cdc.gov/ mmwR/preview/mmwrhtml/ mm5538a1.htm. Accessed January

3, 2007.

2 Best T, van Mechelen W, Verhagen, E. The pediatric athlete-are we

doing the right thing? Clinical Journal of Sports Medicine. 2006; 16

(6). Available online at www.cjsportmed.com. Accessed January 3,

2007.