Physiotherapy for Rickets and Osteomalacia for Undergraduate students

1. Rickets
and
Osteomalacia
DR SREERAJ S R
Physiotherapy for

2. Sreeraj S R
Definitions
RICKETS
o 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
o 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. Sreeraj S R
Role of Calcium
o Calcium serves a major structural role and remains
metabolically stable under normal circumstances.
o 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.
o It has structural and metabolic importance.
3

4. Sreeraj S R
Calcium Metabolism
o 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.
o 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.
o Any upset in this delicate balance either results in increase or
decrease in serum calcium.
4

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

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

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

8. Sreeraj S R
Rickets: signs
1. Frontal bossing
2. Dentition changes
3. Chovstek’s sign
4. Rickety rosary
5. Pigeon chest
6. Malabsorption
7. Aminoaciduria
8. Expanded wrist
9. Pelvis deformity
10.Genu valgum
11.Myopathy
12.Skin changes
8

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

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

11. Sreeraj S R
Rickety rosary
o Enlargement of
costochondral junction.
11

12. Sreeraj S R
Pigeon chest
o due to prominent sternum.
12

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

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

15. Sreeraj S R
Expanded wrist
o 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. Sreeraj S R
Skin changes & Genu valgum
16

17. Sreeraj S R
Pelvis deformity
17

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

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

20. Sreeraj S R
Rickets: Treatment
o Medical treatment in the initial stages is a single oral dose of 6
lakh IU of vitamin D is given.
o 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.
o A maintenance dose of 4,000 IU of vitamin D may be required if
the child responds to the above treatment regimen.
o Absolute and strict bed rest, rickets splints, etc. can help
prevention of deformity.
20

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

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

23. Sreeraj S R
Rickets: Treatment
o Exercises while standing can help increase bone growth but
due to osteoporosis may also be at risk for fractures.
o 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. Sreeraj S R
Osteomalacia: Etiology
o Decreased vitamin D absorption from the intestine.
o Derangement of vitamin D and phosphorus metabolism
(hereditary or acquired).
24

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

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

27. Sreeraj S R
Osteomalacia: Radiographs
o Spine: The bodies of
spine are biconcave
and are called “codfish
spine”.
o 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. Sreeraj S R
Osteomalacia: Treatment
• Primary Prevention/Risk Reduction for Skeletal
Demineralization
• Pain
• Impaired Posture
• Impaired Muscle Performance
• Impaired joint Mobility
• Impaired balance
28

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

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

31. Sreeraj S R
References
1. “Metabolic Disorders.” Textbook of Orthopedics, by John Ebnezar,
St. Louis, Jaypee Brothers Medical Publishers, 2010, pp. 527–539.
2. 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
3. Osteomalacia [Internet]. Physiopedia. 2019 [cited 2020 Sep 13].
Available from: https://www.physio-pedia.com/Osteomalacia
31