زيد حجاب توفيق الكلية التقنية الطبية بغداد قسم العلاج الطبيعي Zaid Hijab Tawfeeq College of Health and medical technology – Baghdad Physiotherapy and Rehabilitation Osteomalacia is softening of the bones. This ineffective bone mineralization in children is referred to as Rickets. It is caused by impaired bone metabolism which in turn causes inadequate bone mineralization. Bone metabolism is impaired due to insufficient calcium, vitamin D or phosphate or calcium resorption.

1. College of Department of
Health and medical technology – Baghdad Physiotherapy and Rehabilitation
Rehabilitation program of bone disease: - in children
(Rickets)
BY:
Zaid Hjab Tawfeeq
Under supervision:
Zainab Ali
M.Sc. Physiotherapy. B. M. Tech.

2. 1
Osteomalacia is softening of the bones. This ineffective bone mineralization in children
is referred to as Rickets. It is caused by impaired bone metabolism which in turn causes
inadequate bone mineralization. Bone metabolism is impaired due to insufficient
calcium, vitamin D or phosphate or calcium resorption.
Mechanism of Injury / Pathological Process
Osteomalacia is due to impaired bone mineralization. The deficiency may be from one of
many causes including lack of sun exposure, poor nutritional intake, low levels of
phosphate, abnormal vitamin D metabolism or drug induced bone mineralization.
Vitamin D deficiency in older adults is the most common cause of osteomalacia.
Clinical Presentation
Typically a person will present with only subtle indicators and diagnosis can easily
be missed. The symptoms are typically diffuse bone pain, fatigue and proximal
muscle pains. A waddling gait may be present due to muscle weakness and hip pain.
A fracture may be the first presenting sign. Bony deformity may be apparent in the
long bones or the pelvis as the condition progresses. ADL may be affected due to
weak and stiff muscles e.g. climbing stairs, sit to stand, carrying loads. Social
activities may be curtailed due to limited mobility. They may initially be
misdiagnosed as fibromyalgia of somatization of depression.

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The common deformities in infantile rickets:
1. Skull:
(a) Craniotabes: The fontanelle remains open even after the age of 2 years.
(b) Frontal bossing: There is prominence (bossing) of the frontal and parietal
bones.
2. Chest :
(a) Pigeon chest: The thoracic cage is compressed at the sides, and is raised
and elongated anteroposterior, the sternum being prominent and thrusted
forward.
(b) Rickety rosary: Bony enlargement occurs at the junction
Of the ribs with cartilages. It gives an appearance of a ‘rosary’, hence the
name.
(c) Harrison sulcus: It is a transverse groove in the anterior part of the lower
chest, caused by the muscular pull of the diaphragm.
3. Spine: Kyphosis involving both the thoracic and lumbar spines may be present
which may subsequently lead to lumbar lordosis as the child starts walking.
4. Abdomen: The abdomen is protuberant and gives a ‘pot-belly’ appearance;
largely due to muscular hypotonic.

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5. Upper limb: There is widening at the epiphyseal regions of the wrist.
Clinical photograph showing widening of the wrist
Radiograph showing cupping and widening of the metaphysis of radius on both sides.

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6. Lower limb:
A. Deformities like coxa vara, genu varum, genu valgum.
Genu valgum deformity.
B. bow-legs or forward bowing of tibia and flat feet occur due to the
compressive pressure of the body weight on soft decalcified bones.
Deformity (bowing) of the tibia and fibula.
C. a peculiar deformity called wind-swept deformity of genu valgum on one side
and genu varum on the contralateral knee may be seen.

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Windswept deformity
7. Pelvis: The size of the pelvis may be reduced; the overall growth of the child
is arrested, all resulting in stunted growth or dwarfism.
Summary Box
Skull • Craniotabes • Frontal bossing
Chest • Pigeon chest • Rickety rosary • Harrison sulcus
Pelvis • Reduced size
Spine • Increased dorsal kyphosis • Lumbar lordosis
Abdomen •pot belly
Extremities • Genu valgum/varum • Bowing of bones • Coxa vara • Wind-
swept deformity

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Diagnostic Procedures
The diagnosis is made from biochemical findings in the blood serum. The main finding is
low vitamin D in the serum. Other major finding are: low calcium in serum and urine;
abnormalities in phosphate (low serum levels) and parathyroid levels (elevated due to
low calcium in serum).
Differential Diagnosis
-Osteoporosis
-Paget’s disease
-Fibromyalgia
-Somatization of depression
-Red flags e.g. cancer or infection
Prevention:
You can help protect your child from the effects of rickets by understanding their risk
factors for vitamin D deficiency and taking steps to prevent it. Suggestions include:
 Sunlight – a sensible balance of sun exposure and sun protection can protect
against vitamin D deficiency without putting your child at risk of skin cancer. The
recommended amount of sunlight each day is a few minutes of sunlight exposure
before 10am and after 3pm each day (from September to April) and two to three
hours of sunlight exposure over the week (from May to August). Always protect
your child’s skin from the sun during peak UV times with clothing, shade and/or
sunscreen.
 Diet – include food rich in vitamin D and calcium in your child’s diet. Foods
naturally containing vitamin D include oily fish (especially sardines, salmon,
herring and mackerel), liver and egg yolks. Foods ‘fortified’ with vitamin D include
some margarines and some milks (including fortified baby formula milk).
 Supplements – consult with your child’s doctor or health provider about whether
your child should be prescribed supplements.

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Management / Interventions
The main treatment to address the bone mineralization issue is to increase vitamin D
intake. This should be overseen by the consulting doctor to check vitamin D levels and
check on progress. This may be through medication or ensuring sufficient nutritional
intake of vitamin D and increasing exposure to the sun. Fifteen minutes of sunshine a
day may be adequate. Use of sunscreen lotions can be a factor in development of
Osteomalacia in at risk populations. As a physiotherapist you may be educated in dietary
advice or wish to refer person on to a dietician for more formal advice.
Physiotherapeutic and rehabilitation management:
Objectives:
◼ Prevention of deformities (at the trunk and limbs).
◼ Maintain or improve muscle functions and ROM.
◼ Functional re-education.
Early stage: The most important stage when a sick and irritable child is likely to
develop multiple problems such as general debility, hypotonic, weakness of the
proximal limb muscles and the spinal group of muscles.
1. Therefore, correct education of the mother as regards positioning, handling and
carrying the child and not allowing weight bearing is important to prevent limb
deformities or even fractures.
2. General body exposure to UV rays at sub thermal dose of 3300–2900 A is useful.
3. Put the child on the floor in different positions and let it perform free movements
of the limbs and the trunk.
4. Chest physiotherapy helps in improving general health by increasing oxygen
uptake and also in preventing chest infection. As the general condition improves,
child will become more active. For chest physiotherapy, if active exercises are not
possible, passive (gentle) breathing exercises can be given.
5. Initiate intelligent objective modes of getting purposeful functional exercises
done, offering resistance wherever possible (e.g., kicking a ball).

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6. Initiate controlled resistive proprioceptive neuromuscular facilitation (PNF)
patterns with guided assistance.
7. If a child attempts to stand and walk, provide orthosis or a brace to prevent limb
deformities when there is definite evidence of calcification.
Late stage: Increase the vigorousity of exercise concentrating mainly on the functional
muscle groups. Continue progression till the child is functionally self-sufficient and free
from deformity.
Child using molded orthoses left inferior limb. Observe the three full contact points (thigh inner edge,
outer edge of the proximal tibia, and distal inner edge of the tibia), promoting decompression on the
medial proximal edge of the tibia.
Following surgery: Surgery is mostly undertaken to treat fractures and correct
deformities by osteotomy. Appropriate physiotherapeutic measures of progressive
mobilization and strengthening of the related muscle groups facilitates early return of
function. Though these measures appear easy, tremendous long-standing effort is
needed to successfully manage a child with rickets. The child may be given supportive
orthoses to give ambulatory training, which could be gradually waned and discarded
later.

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References
1. Walker J. Pathogenesis, diagnosis and management of osteomalacia. Nursing older people.
2014 Jun 30; 26(6). Available from: Walker J. Pathogenesis, diagnosis and management of
osteomalacia. Nursing older people. 2014 Jun 30;26(6).(last accessed 26.2.2019).
2. Jayant Joshi, Prakash Kotwal. Essentials of Orthopedics and Applied Physiotherapy. 3rd
edition. Elsevier. 1999. Pp 252-260.