4.2 Congenital disorders

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4. Pediatrics

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Congenital disorders

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Congenital disorders are conditions in which an individual develops in utero, during birth, or shortly after birth. The reasons for the development of congenital disorders can be due to gene mutations, deoxygenation to the brain or heart, infections, or micronutrient deficiencies. The contents of this chapter will cover common congenital disorders.

Cerebral palsy

Cerebral palsy (CP) is a group of disorders causing deficits in movement and coordination. CP can be caused by abnormal development or damage to the brain. The timeline for damage can occur before birth, during birth, or shortly after birth. Damage can be from intracranial hemorrhage, lack of oxygen to the brain, abnormal development of the brain, or damage to the white matter in the brain.

The risk of development of CP increases with multiple births, exposure to toxic substances, infections by mother and/or infant, low birth weight, seizures, complicated birth/labor, jaundice, or breech birth (feet first during birth).

Common issues for those with cerebral palsy can be intellectual disabilities, visual impairments, speech and language deficits, seizures, hearing impairments, and various orthopedic conditions.

Types of cerebral palsy

Spastic cerebral palsy (Hypertonic cerebral palsy)
- Type of cerebral palsy in which the individual exhibits hypertonia, causing stiff and jerky movements
  - Spastic hemiplegia
    - Hypertonia is located on one side of the body; the ipsilateral arm and leg
    - Side of dysfunctions is typically shorter and thinner, scoliosis may be present, and intellect is normal
  - Spastic diplegia
    - Hypertonia is located primarily in the lower extremities
    - Hyperreflexia can be present, scissoring of gait, and intellect is normal
  - Spastic quadriplegia
    - Hypertonia is located throughout the entire body
    - The most severe type of spastic cerebral palsy is due to widespread damage to the entire brain
    - Individuals with this type of CP rarely walk, demonstrate difficulty speaking, and can have some intellectual difficulty
Hypotonic cerebral palsy
- Characterized by low tone and floppiness of extremities and axial skeleton
- Individuals may demonstrate poor muscle tone, excessive range of motion, increased weight gain, impaired speech due to poor oral motor control, and wide base support with gait
Dyskinetic cerebral palsy (Athetoid cerebral palsy)
- Characterized by slow and uncontrollable writhing or jerky movements of the hands, feet, arms, and legs
- Individuals may demonstrate postural deficits, hearing problems, and breathing difficulties; their intellect remains intact
Ataxic cerebral palsy
- Characterized by poor coordination, balance impairments, and impairments in depth perception
- Individuals may demonstrate a wide base of support, dysmetria, and difficulty with the precision of movements
Mixed types
- Characterized by mixed muscles of hypertonia and hypotonia with varied symptom presentation

Classifications of cerebral palsy

Level I: Walks without limitations (mild).
Level II: Walks with some limitations, needs aids for long distances.
Level III: Walks with assistive devices (walkers, crutches).
Level IV: Limited mobility, mostly uses wheelchairs.
**Level V:**Severe mobility impairment, needs power wheelchair and significant assistance (severe).

Physical therapy interventions for cerebral palsy

Positioning is key to promote improvements in mobility, ADL participation, gait and balance improvements, and interaction with the environment.
- Symmetrical posture
- Alignment of trunk, pelvis, and extremities
- Head in midline
- Hips and knees in 90 degrees in sitting
- Prescription of orthoses
- Optimizing functional motor skills
Treatment of visual-motor and perceptual disorders
- Aids to assist with visual processing, aiding in connecting the visual system to the brain
Treatment of orthopedic conditions such as
- Scoliosis
- Joint contractures
- Kyphosis
- Clubfoot
- Hip or shoulder dislocation

Medical management for cerebral palsy

Anti-seizure medication
Spasticity mediation
- Botox injections for local hypertonic muscles
- Baclofen taken orally or by implantation for multiple areas of hypertonia
Surgical interventions
- Dorsal rhizotomy:
  - Dorsal nerve roots are served to aid in decreasing spasticity and improving overall function
- Z-plasty
  - Release of muscle or tendons to release contractures

Down syndrome

Down syndrome is the result of a chromosomal abnormality on chromosome 21. Chromosome 21, which would normally only have a pair of DNA, has three strands of DNA, causing Down Syndrome.

Characteristics of Down syndrome include:

Small ears and a protruding tongue
Microcephaly with flattened occiput
Short stature
Hypotonia and hypermobility
Congenital heart defects
Speech deficits
Developmental delays
Vertebral instability at the atlanto-axial joint (C1-C2)
Intellectual disabilities

Physical therapy interventions for Down syndrome

Promote gross motor development
Increase motor control and postural awareness
Improve oral-motor development
Durable medical equipment recommendations as appropriate
Patient and family education

Special considerations with Down’s syndrome

Avoidance of diving, tumbling, headstands, and contact sports due to increased risk for hyperflexion injuries due to atlanto-axial instability

Duchenne muscular dystrophy

Duchenne muscular dystrophy is a progressive disease process in which the protein dystrophin is not produced, thus causing an increased breakdown of muscle tissue over time. Most often affects boys and has a life expectancy of the early 20s.

Common symptoms of Duchenne muscular dystrophy

Progressive muscle weakness
Pseudohypertrophic muscles appear hypertrophied, but the muscle has been replaced by fat and connective tissue in calves, deltoids, quadriceps, and tongue
Contracture
Cardiac myopathy
Gower’s sign
- The child pushes up from the floor with their hands, walking their hands up their legs to stand- this is due to weak hip and knee extensors; typically begins at ages 4-7
Waddling gait
Increased risk of falls

Progression of Duchenne muscular dystrophy

Age 3-5: weakness, tripping, Gower’s sign is present
Age 9-11: gait deviations leading to high energy expenditure occur, unable to ascend/ descend stairs; poor endurance; bracing may be required for ambulation; loss of ability to ambulate occurs
Age 12-14: use of manual wheelchair, increased weight gain, contracture of lower extremity joints
Age 15-17: increased respiratory compromise, total dependence for ADL, and all mobility
Young adulthood: death in early 20s due to respiratory compromise

Physical therapy interventions for Duchenne muscular dystrophy

Maintain range of motion
Assess mobility and attempt to maintain the current level of mobility
Provide durable medical equipment as appropriate
Parent and patient education

Medical management for Duchenne muscular dystrophy

Treatments of symptoms as appropriate
Use of medications such as steroids, antibiotics as needed
Treatment of orthopedic conditions through injections or surgery

Spinal muscular atrophy (SMA)

Spinal muscular atrophy is a group of congenital disorders in which the motor neurons within the spinal cord demonstrate dysfunction. The motor unit dysfunction is caused by mutations in genes that do not allow for the natural survival of the motor unit.

Common symptoms associated with SMA are: muscle contractures, muscle weakness, scoliosis, difficulty with functional mobility, difficulty swallowing, and impairments in the respiratory system. Symptoms are progressive throughout the lifespan of an individual.

Diagnosis is confirmed via physical examination, genetic testing, and electrical velocity testing.

Five types of SMA:

Type 0 (Zero)
- Presents at birth; muscle atrophy and severe muscle weakness present; leads to life-threatening respiratory compromise
Type 1 (Infantile)
- Presentation within the first 6 months of life; muscle weakness specifically impacting feeding, crawling, and sitting
Type 2 (intermediate)
- Presentation between 6-18 months of life; progressive muscle weakness in the hips, legs, and trunk
Type 3 (Juvenile)
- Presentation between 18 months and -18 years; muscle weakness in the back, legs, and feet
Type 4 (Adult)
- Presentation after 18 years of age; mild symptoms that present later in life

Physical therapy interventions for SMA

Physical therapy interventions are based upon the level of impairment associated with the SMA and can include progression to meet developmental milestones, improvements in range of motion, improvements in balance, improvements in posture, strengthening muscles, and initiation of energy conservation strategies.

Spina bifida

Spina bifida is a neural tube defect resulting in vertebral and/or spinal cord malformation secondary to elevated serum amniotic alpha fetoprotein in utero. This elevation is due to a deficiency in folic acid.

Common symptoms associated with spina bifida are:

Flaccid or spastic paralysis
Bladder incontinence
Musculoskeletal deformities (scoliosis, hip dysplasia, hip dislocation, club foot, hip/knee contracture)
Hydrocephalus, along with Type I or II Arnold-Chiari malformation

Definitions

Hydrocephalus: Increased cerebrospinal fluid in the ventricle of the brain; the increased fluid accumulation in the ventricles causes increased pressure on other structures within the brain
Arnold-Chiari malformation: Structural defect in which the cerebellum pushes down into the spinal canal; often associated with hydrocephalus

Three (3) types of spina bifida:

Spina bifida occulta
- No spinal cord involvement
- Depression or dimple in the lower back
- A small patch of dark hair
- Soft fatty deposits
- Port-wine nevi (deep red-purple macular lesions)
- Minimal disability, if any
Spina bifida meningocele
- No spinal cord involvement
- Meninges protrude through the skin
- Cerebrospinal fluid may leak
- Associated diagnoses: club foot, hip dysplasia, hydrocephalus
- Moderate disability
Spina bidia myelmeningocele
- Spinal cord involvement
- Protrudes through the skin
- Severe disability will result
  - Paralysis usually occurs

Physical therapy and spina bifida interventions

Joint ROM
Axial and trunk strengthening and engagement
Positioning and handling (specifically for infants)
Mobility and balance

Developmental dysplasia of the hip (DDH)

A congenital condition in which the hip joint develops abnormally, resulting in the acetabulum being too shallow to properly fit the femoral head. The abnormal fit allows for consistent dislocation, leading tan o an inability to appropriately meet developmental milestones. Factors that contribute to the development of DDH are the first pregnancy, breech birth, swaddling too tightly with legs extended, and increased infant size. Diagnosis of developmental dysplasia of the hip includes physical examination, x-ray, and ultrasound.

Common symptoms are:

Leg length discrepancy (affected leg is shorter than the unaffected)
Increased folds in the skin of the thigh/buttocks of the affected extremity
Increased popping noted when moving the affected leg
- Ortalani test
  - Movement in flexion and abduction to 90 degrees causes an audible clunk or pop when attempting to perform
- Barlow test
  - Movement in flexion and adduction to 90 degrees causes an audible clunk or pop when attempting to perform

Physical therapy interventions and DDH

Education provided to the family for the appropriate positioning of the infant to reduce hip dislocation occurrence
Gentle range of motion activities that do cause dislocation
Wearing of Pavlick harness
- The Pavlick harness is a soft splint used to allow for consistent contact between the acetabulum and the femoral head
  - Positioned in abduction of legs, hip flexion, and knee flexion through a series of straps to keep the infant in this position
- Used for infants 6 months or younger with the goal of 24-hour wearing for the first 6 weeks and progressing to 6 weeks of wearing only at night
  - The parents must learn how to care for the baby fully during the time of consistent wearing
  - Change from wearing 24 hours a day to only a night is determined by an orthopedic physician via x-ray and ultrasound
  - Developmental delay may occur in an infant due to constant positioning, as mentioned above, with decreased ability to move out of position

Club foot

Clubfoot is a congenital disorder in which the foot is turned down and inward due to a shortened Achilles tendon. Etiology is unknown, but it could be due to the imbalance development of the tendon muscles in the foot during pregnancy or related to spina bifida. The diagnosis is confirmed via physical therapy examination and X-ray imaging.

Phases of intervention are as follows:

Phase 1: serial casting
- Club foot is stretched/manipulated to improve the range of motion, and then a hard cast is set in place over the affected extremity
  - The hard cast is removed, and stretching occurs again, with a new cast put in place with the new range of motion that has been achieved
  - The goal is to wear the hard cast until normal alignment is achieved - can take 4-10 weeks to achieve normal alignment

Phase 2: bracing
- Once serial casting is complete (normal alignment is achieved), bracing is put in place to aid in maintaining the normal alignment of the foot
  - The timeframe for bracing can vary depending on the severity of the original club foot deformity

Surgical intervention may be necessary depending on the severity of the deformity and the inability to change Achilles tendon length through conservative measures.

Physical therapy interventions

Physical therapy is important in performing serial casting, recommending appropriate bracing options, and intervening if any developmental delays have occurred due to club foot and/or club foot interventions.

Osteogenesis imperfecta

Osteogenesis imperfecta is a group of genetic disorders that impacts an individual’s ability to produce strong, healthy bones (decreased osteoblast activity). Osteogenesis imperfecta can increase the risk of bone fractures with minimal impact.

Symptoms of osteogenesis imperfecta:

Short stature
Joint laxity,
Frequent fractures
Bone deformities,
Muscle weakness,
Hearing loss
Dental problems.

There are varying degrees of severity of osteogenesis imperfecta, which range from mild symptoms that will persist throughout life to severe symptoms in which the newborn dies within weeks of birth.

Physical therapy interventions and osteogenesis imperfecta

Education is provided to parents on swaddling techniques, positioning, handling, and fall prevention techniques as progression through developmental milestones.

Arthrogryposis multiplex congenita (AMC)

Arthrogryposis multiplex congenita (AMC) is a rare, non-progressive congenital condition characterized by multiple joint contractures found in at least two different body areas. These joint deformities are present at birth and result from limited fetal movement in the womb. The condition is not a single disease but a clinical finding that may have several underlying causes, primarily involving the neuromuscular system.

The primary cause of AMC is decreased fetal movement (fetal akinesia), which is essential for normal joint and muscle development. When a fetus does not move adequately in utero, the joints do not develop normally, and soft tissues like muscles and tendons can become contracted.

Clinical presentation

Multiple joint contractures at birth (e.g., clubfoot, extended knees, flexed wrists)
Muscle hypoplasia or replacement of muscle tissue with fibrous or fatty tissue
Thin, atrophic limbs
No progressive neurological decline
Normal cognitive function in most cases

Common postural patterns:

Shoulders: Internal rotation and adduction
Elbows: Extended or flexed, depending on the subtype
Wrists: Flexed and ulnarly deviated
Hands: Clenched with thumb-in-palm deformity
Hips: Abducted and externally rotated or dislocated
Knees: Hyperextended or flexed
Feet: Clubfoot (equinovarus) deformities

Medical and physical therapy management

Physical therapy interventions

Passive range of motion (PROM): Initiated early to maintain or improve joint flexibility
Stretching: Daily stretching programs to prevent worsening
Positioning: Using splints or orthoses to maintain joint alignment
Serial casting: For correcting severe deformities gradually
Strengthening exercises: Focused on available muscle groups
Mobility training: Use of assistive devices (walkers, wheelchairs, KAFOs)
Gait training (if lower extremities involved)

Orthotic management

AFOs or KAFOs for ambulation
Hand splints to improve function
Spinal orthoses if scoliosis develops

Surgical interventions

Tendon transfers
Joint release
Clubfoot correction (e.g., Ponseti method or surgical release)
Hip or knee reconstructions in severe deformities

Cerebral palsy

Group of movement and coordination disorders from brain damage or abnormal development
Risk factors: multiple births, infections, low birth weight, birth complications
Associated issues: intellectual disabilities, visual/speech/hearing impairments, seizures, orthopedic conditions

Types of cerebral palsy

Spastic: hypertonia, stiff/jerky movements; subtypes—hemiplegia, diplegia, quadriplegia
Hypotonic: low muscle tone, floppiness, poor oral motor control
Dyskinetic: slow/jerky involuntary movements, postural deficits, intellect intact
Ataxic: poor coordination, balance, depth perception
Mixed: combination of hypertonia and hypotonia

Classifications of cerebral palsy

Level I-V: from walks without limitations (I) to severe mobility impairment (V)

Physical therapy interventions for cerebral palsy

Emphasis on positioning, symmetrical posture, trunk/pelvis alignment
Treatment of visual-motor, perceptual, and orthopedic disorders

Medical management for cerebral palsy

Anti-seizure and spasticity medications (Botox, Baclofen)
Surgical interventions: dorsal rhizotomy, Z-plasty

Down syndrome

Chromosomal abnormality: trisomy 21
Features: small ears, protruding tongue, microcephaly, hypotonia, heart defects, developmental delays, atlanto-axial instability

Physical therapy interventions for Down syndrome

Promote gross motor and oral-motor development
Increase motor control, postural awareness, family education

Special considerations

Avoid activities risking neck injury (e.g., diving, tumbling) due to atlanto-axial instability

Duchenne muscular dystrophy

X-linked disorder, absence of dystrophin, progressive muscle breakdown
Affects boys, life expectancy: early 20s

Symptoms

Progressive muscle weakness, pseudohypertrophy, contractures, cardiac myopathy
Gower’s sign, waddling gait, frequent falls

Progression

Age 3-5: weakness, Gower’s sign
Age 9-11: gait loss, bracing needed
Age 12-14: wheelchair use, contractures
Age 15-17: respiratory compromise, total dependence

Physical therapy interventions

Maintain ROM, mobility, provide equipment, education

Medical management

Symptom management, steroids, antibiotics, orthopedic surgery

Spinal muscular atrophy (SMA)

Genetic motor neuron disorder, progressive weakness, contractures, scoliosis, respiratory/swallowing difficulties

Types of SMA

Type 0: at birth, severe, life-threatening
Type 1: <6 months, feeding/crawling/sitting weakness
Type 2: 6-18 months, hip/leg/trunk weakness
Type 3: 18 months-18 years, back/leg/foot weakness
Type 4: >18 years, mild symptoms

Physical therapy interventions

Address developmental milestones, ROM, balance, posture, strengthening, energy conservation

Spina bifida

Neural tube defect from folic acid deficiency, elevated amniotic alpha fetoprotein

Symptoms

Flaccid/spastic paralysis, bladder incontinence, musculoskeletal deformities, hydrocephalus, Arnold-Chiari malformation

Types

Occulta: no cord involvement, minimal disability
Meningocele: meninges protrude, moderate disability
Myelomeningocele: cord involvement, severe disability/paralysis

Physical therapy interventions

Joint ROM, trunk strengthening, positioning, mobility/balance

Developmental dysplasia of the hip (DDH)

Shallow acetabulum, frequent dislocation, delayed milestones
Risk factors: first pregnancy, breech, tight swaddling, large infant

Symptoms

Leg length discrepancy, extra thigh/buttock folds, positive Ortolani/Barlow tests

Physical therapy interventions

Family education on positioning, gentle ROM, Pavlik harness use

Club foot

Foot turned down/inward, shortened Achilles tendon, possible link to spina bifida

Intervention phases

Phase 1: serial casting to correct alignment (4-10 weeks)
Phase 2: bracing to maintain alignment

Physical therapy interventions

Serial casting, bracing recommendations, address developmental delays

Osteogenesis imperfecta

Genetic disorder, decreased osteoblast activity, brittle bones

Symptoms

Short stature, joint laxity, frequent fractures, bone deformities, muscle weakness, hearing loss, dental issues

Physical therapy interventions

Parent education on handling, positioning, fall prevention

Arthrogryposis multiplex congenita (AMC)

Non-progressive, multiple joint contractures at birth due to decreased fetal movement

Clinical presentation

Multiple contractures, muscle hypoplasia, thin limbs, normal cognition

Common postural patterns

Shoulders: internal rotation/adduction
Elbows/wrists/hands: extended/flexed, ulnar deviation, thumb-in-palm
Hips/knees/feet: abduction, hyperextension/flexion, clubfoot

Management

Early PROM, stretching, positioning, serial casting, strengthening, mobility/gait training
Orthoses: AFOs, KAFOs, hand splints, spinal supports
Surgery: tendon transfers, joint release, clubfoot/hip/knee corrections

Congenital disorders

Cerebral palsy

Common issues for those with cerebral palsy can be intellectual disabilities, visual impairments, speech and language deficits, seizures, hearing impairments, and various orthopedic conditions.