Physiotherapy for Rickets and Osteomalacia

Physiotherapy for Rickets and Osteomalacia for Undergraduate students

1. Rickets and Osteomalacia Dr Sreeraj s r Physiotherapy for

2. Definitions RICKETS It is a metabolic disease of childhood in which, the osteoid, the organic matrix of bone, fails to mineralize due to interference with calcification mechanism. OSTEOMALACIA It is the adult counterpart of rickets and is characterized by failure of mineralization and an excess of osteoid due to an interference with calcification mechanism. 2

3. Role of Calcium Calcium serves a major structural role and remains metabolically stable under normal circumstances. Calcified bone contains about 25% organic matrix (2-5% of which are cells), 5% water and 70% inorganic mineral, hydroxyapatite ( Ca10 (PO4)6 (OH)2), the main mineral deposited on the organic matrix as calcium . It has structural and metabolic importance. 3

4. Calcium Metabolism Vitamin D, PTH, bile salts, calcitonin help in the absorption of calcium from the upper small intestine, while the oxalates, citrates, phosphates, phytic acids and fats impair absorption. Hormones, which help calcium to be deposited into the bone, are estrogen , thyroxin, growth hormone and testosterone, while that which remove the calcium from bone are glucocorticoids, thyroid hormones, PTH and acidosis. Any upset in this delicate balance either results in increase or decrease in serum calcium. 4

5. Rickets: causes Vitamin D deficiency: Reduced dietary intake Reduced amount of sunlight Pigmented skin. Malabsorption due to: Celiac disease Hepatic osteodystrophy. Renal disease: Glomerular failure Renal osteodystrophy. Antiepileptic drugs favors formation of hepatic enzyme, which prevents conversion of calciferol. 5

6. Rickets: varieties Type I: This is due to dietary deficiency or defects in metabolism of vitamin D. Type II: This is due to low serum phosphorus due to dietary phosphate deficiency or defective tubular resorption. Type I dietary deficiency of vitamin D is the most common variety of rickets. 6

7. Rickets: symptoms Delayed growth Delayed motor skills Pain in the spine, pelvis and legs Muscle weakness 7

8. Rickets: signs Frontal bossing Dentition changes Chovstek’s sign Rickety rosary Pigeon chest Malabsorption Aminoaciduria Expanded wrist Pelvis deformity Genu valgum Myopathy Skin changes 8

9. Frontal bossing Broadened forehead Skull squared (caput quadratum) Frontal and parietal bossing—seen after the age of 6 months. 9

10. Chovstek’s sign It is a clinical sign of  hypocalcemia  which consist of twitching of muscles innervated by facial nerve. It refers to an abnormal reaction to the stimulation of the facial nerve. 10

11. Rickety rosary Enlargement of costochondral junction. 11

12. Pigeon chest due to prominent sternum. 12

13. Narrow chest Costochondral dysplasia (short rib size). Ribs cannot extend anteriorly, resulting in anteroposterior and lateral thoracic diameters reduction (narrow chest). The highlights include alveolar hypoventilation and lung growth restriction. Also Jeunes Syndrome 13

14. Harrison’s sulci Symmetrical horizontal grooves above the costal margin, along the line of attachment of diaphragm. Due to diaphragmatic pull on the soft ribs. 14

15. Expanded wrist Enlargement of the metaphyseal segments of long bones like radius, tibia, costochondral junction, etc. seen in children between 6 and 9 months of age. 15

16. Skin changes & Genu valgum 16

17. Pelvis deformity 17

18. Rickets: X-ray findings Characteristic Lovette and Jones radiological changes Delayed appearance of epiphysis and widening of the epiphyseal plates. Champagne glass appearance (widening and cupping of the distal ends of long bones) also called ‘trumpeting’. Space between diaphysis and epiphysis is increased. Deformity and bowing of the ends of long bones. Thickened epiphysis. Decreased density of cortex (rarefaction). Coarse trabecular pattern in bone. 18

19. Rickets: Differential Diagnosis Acute poliomyélites Congenital syphilis Septic arthritis Infantile scurvy Renal tubular acidosis Malabsorption syndromes Prematurity 19

20. Rickets: Treatment Medical treatment in the initial stages is a single oral dose of 6 lakh IU of vitamin D is given. A second same dose may be required after 3-4 weeks of treatment if no sclerotic (healing sign) change is seen on the radiograph at the metaphyseal side of the growth plate. A maintenance dose of 4,000 IU of vitamin D may be required if the child responds to the above treatment regimen. Absolute and strict bed rest, rickets splints, etc. can help prevention of deformity. 20

21. Rickets: Treatment Correction by splints (Mermaid splint): This is mainly useful when the disease is active, and the deformity is slight. It is very effective in children and in preventing deformities concerning the lower limbs. However, it is slow and requires continual supervision. Correction by osteotomy is indicated when deformity is near the joint and when the growth stops. It is done during III stage (Lovett’s) ( nonunion follows if done before). 21

22. Rickets: Treatment There are no direct physical therapy interventions for Rickets or Vitamin D deficiency. Patient will be referred to physical therapy for treatment of impairments such as decline in muscle strength, decline in physical functioning, or falls prevention. Physical therapists can take a team approach with medical management through patient education on: Foods high in Vitamin D Importance of following medical recommendations Importance of proper sun exposure with risks of overexposure 22

23. Rickets: Treatment Exercises while standing can help increase bone growth but due to osteoporosis may also be at risk for fractures. Physical therapy can help to also reduce any bone or muscle pain through stretching and strengthening exercises as well as hands on manual techniques. 23

24. Osteomalacia : Etiology Decreased vitamin D absorption from the intestine. Derangement of vitamin D and phosphorus metabolism (hereditary or acquired). 24

25. Osteomalacia : Clinical Features The patient complains of generalized skeletal pain and muscle weakness. Other symptoms related to causative factors like dietary, renal and GIT may be seen. The following deformities are encountered; scoliosis, kyphosis, coxa vara , protrusioacetabuli , thighs and legs are bent, pelvis is trefoil, etc. 25

26. Osteomalacia : Radiographs Radiographic features reveal generalized demineralization, loss of transverse trabeculae, no subperiosteal resorption of bone, etc. Presence of Looser’s zones is quite characteristic of osteomalacia . 26 Case courtesy of Radswiki , Radiopaedia.org, rID : 11585

27. Osteomalacia : Radiographs Spine: The bodies of spine are biconcave and are called “codfish spine”. Hip show protrusioacetabuli and triradiate pelvis. 27 https://assets.cureus.com/uploads/figure/file/32017/fb167130288a11e8b9db9304fcf484ba-Figure-12_Formatted_V1-PME.PNG Case courtesy of Dr Dalia Ibrahim, Radiopaedia.org, rID : 58864 https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-78522002000400007#:~:text=Protrusio%20acetabuli%20is%20a%20disease,and%20limited%20limb%20hip%20movement.

28. Osteomalacia : Treatment Primary Prevention/Risk Reduction for Skeletal Demineralization Pain Impaired Posture Impaired Muscle Performance Impaired joint Mobility Impaired balance 28

29. Osteomalacia : Treatment Calcium is given at 0. Osteomalacia : Treatment 5-3 gm/day, vitamin D 10,000 IU/day, and high protein diet. The gastrointestinal tract errors are also corrected simultaneously. Fifteen minutes of sunshine a day may be adequate. 29

30. Osteomalacia : Treatment Physiotherapy plays an important role in a multidisciplinary approach to treatment. Tailored exercise programs are important to ensure strengthening of major muscle groups and improvement in ADL and social activities.  Weight bearing exercises should be encouraged such as walking but not intensive or high impact exercises. A similar approach can be taken as to exercise programs for osteoporosis. 30

31. References “Metabolic Disorders.”  Textbook of Orthopedics , by John Ebnezar , St. Louis, Jaypee Brothers Medical Publishers, 2010, pp. 527–539. ‌Tbilisi State Medical University. Rickets in children [Internet]. Slideshare.net. 2014 [cited 2020 Sep 13]. Available from: https://www.slideshare.net/jinujvarghese/rickets-in-children-42660531 Osteomalacia [Internet]. Physiopedia . 2019 [cited 2020 Sep 13]. Available from: https://www.physio-pedia.com/Osteomalacia 31