The Importance of Physiotherapy in Promoting Bone Health for Children Supported by VAD: Early Mobilisation and Weight Bearing Guidelines

Abstract

Purpose Critically ill children are at risk of bone loss due to a multitude of factors including immobility. For children who require cardiac transplantation, with or without ventricular assist device (VAD) support, reduced mobility is particularly evident. This is due in part to the severity of the child's condition and environmental limitations. Bone loss is known to be a significant risk factor for fractures which can perpetuate immobility. We reviewed patients who developed bone fractures at our institution and aimed to describe the impact of physiotherapy on their care. Methods Patients listed or within 6 months of cardiac transplant were identified from the physiotherapy transplant/VAD database. We performed a retrospective case series analysis identifying risk factors for the development of bone fractures and analysed the physiotherapy programmes. We subsequently carried out a literature review looking at factors in physiotherapy management which impact outcomes and provided guidelines for patient management. Results Between 2015 to 2017 3 of 45 cardiac transplant patients developed an atraumatic femoral bone fracture: two whilst supported on VAD and one immediately post discharge after transplantation. The children on VAD were 18 weeks and 19months old. Diagnosis was dilated DCM and late presentation ALCAPA. Both children required long tern ventilation support via tracheostomy . The third child was 37 months with a failing Fontan circulation supported medically in our PICU before transplant. All 3 received prolonged unfractionated heparin. All three children had daily physiotherapy as per our standard protocol. Conclusion Physical activity, complete nutrition and exposure to sunlight are known key elements of optimal bone health and all of these are severely limited in a young child on VAD support. Physiotherapy is a key factor in improving physical activity in children on VAD support but there are currently no published recommendations for the prevention of bone fractures while on VAD. We believe aggressive physiotherapy using protocols similar to those used for children not on VAD support with a focus on weight bearing are needed for these patients. We present a mobilisation protocol including weight bearing guidelines, as part of a comprehensive bone health strategy.