What can parents of children with Cerebral Palsy do to help prevent or reduce hip dysplasia?
Cerebral Palsy (CP) has been described as “a group of disorders of the development of movement and posture, causing activity limitation, that are attributed to, non-progressive disturbances that occurred in the developing fetal or infant brain”.
How Hip Dysplasia Develops
One significant consideration for children with CP throughout their lifetime is the risk of orthopedic complications, with reports that 35% of all children with CP develop hip displacement.
Most infants with CP are born with healthy hips; however, because of the prolonged impact of unbalanced muscle tone and spasticity on the child’s movement and positioning, and increasing muscle tightness of the hip adductors and flexors, the femur is gradually pulled away from the acetabulum.
Femoral ante-version and acetabular dysplasia due to decreased weight bearing also contribute to hip instability.
Gross Motor Function Classification Level System (GMFCS)
As CP is a heterogeneous group of disorders, children with CP are described by the type of CP as well as their gross motor function level.
Clinicians, researchers, and parents use the reliable and valid Gross Motor Function Classification Level System (GMFCS) to classify a child with CP’s ability to move.
The GMFCS has 5 ordinal levels based on age-related gross motor functional abilities from birth to 18 years of age.
Studies have shown that children diagnosed with CP and classified in the GMFCS levels IV and V are at the greatest risk of hip displacement with a 68-90% incidence of the condition, while 39-50% of children in GMFCS Level III will present with subluxation of dislocation.
Age is also a factor, with hip displacement most commonly occurring at 3-4 years of age.
Hip displacement is a serious health concern for these children: it causes pain and reduced mobility and can have significant impacts on their quality of life.
How Hip Displacement is Determined
Hip displacement occurs when the Migration Percentage (MP) is greater than 33%.
Reimers Migration Percentage (MP) is defined as the migration percentage of the femoral head outside the lateral acetabular margin.
Determining MP using radiological assessment is accepted as the most reliable way to measure hip displacement.
At 40% MP, reconstructive or preventative orthopaedic surgery is recommended, while hip dislocation normally occurs when the migration is more than 60%.
There are a variety of surgical options recommended to prevent complete hip dislocation and minimize the risk of the associated consequences once MP reaches 40%.
Yet most preventative surgical options are quite invasive and children can have a long recovery.
Complications following these surgeries are common, with high re-operation rates of up to 74% occurring in this population group (9).
World-wide hip surveillance guidelines have been established over the last 10 years to educate clinicians working with these children on early displacement identification, through a routine x-ray system according to GMFCS level, and suggest early preventative surgery.
Despite the development and implementation of hip surveillance programs, there remains a lack of clinical best practice guidelines or recommendations on non-invasive, preventative interventions for children with CP.
Several non-invasive interventions have been studied in children with CP to evaluate the efficacy of preventing hip displacement, including:
- Botulinum Toxin A and Bracing
- Botulinum Toxin A
- Positioning systems for sitting and sleeping
- Standing frames
- Complementary and alternative medicine
- Obturator nerve block
- Pressure Orthosis
In the interim, clinical practice outcomes have shown that preventative care may be an option.
There are no clinical guidelines on standard preventative interventions to assist physiotherapists in instructing parents of children with CP, and no research on what interventions are actually implemented by the parents and how often.
Thus, physiotherapists and physical therapists working with this population are challenged and must rely on clinical reasoning to prevent or delay these orthopedic complications from developing through non-invasive interventions.
8 Interventions Recommended by Physical Therapist and Author, Jo-Anne Weltman
The writer suggests the following interventions, obtained from clinical experience and orthopedic reasoning, as ways to prevent or slow hip dysplasia in children with Cerebral Palsy and other diagnoses.
These interventions need to be completed daily over the full 24 hours to be effective (24-hour positioning).
- Wheelchair/stroller/activity chair with abduction pommel
- Standing Frame in abduction
- Corner chair or NADA Chris sitting in abduction and external rotation (with leg immobilizers and AFO’s)
- Hip orthosis (Maple Leaf Orthosis, S.W.A.S.H., Boston Brace or other) or Sleep Positioning System for positioning at night
- Hip rotation straps for gait training (Ryders Test needs to be completed first)
- Daily Prone Lying (with or without wedge) to stretch out hip flexors
- NeuroMuscular Electrical Stimulation (NMES) to adductors, glutes, and lateral hamstrings
- Selective Percutaneous Myofascial Lengthening (SPML) or Botulinum Toxin A (Botox/BoNT-A) to adductors and hamstrings
Guidelines do exist for babies with Development Dysplasia of the Hip (DDH) who are required to wear a Pavlik harness for 23 hours a day for 6-12 weeks to reduce and correct the dysplasia.
For this and other orthopedic conditions, the amount of treatment time required to correct the condition or prevent it from progressing needs to be greater than the amount of time where the condition is not treated.
The position of dislocation of the hip is flexion, adduction, and internal rotation.
Thus by providing 24-hour positioning in abduction, and external rotation, we can attempt to prevent this gradual and silent dysplasia.
About the Author
Jo-Anne Weltman graduated from Wits University in Johannesburg, South Africa in 1991 with a B.S.c. in Physiotherapy.
Since then she has completed her MRSc. with research in hip dysplasia in Cerebral Palsy. She has taken numerous courses over the years including NDT, Conductive Education, Therapeutic Taping, Theratogs application, Therasuit Approach, TASES (NMES), Vestibular-Ocular therapy, CVI, CME III, Reflex Integration, Sensory Integration, Orthopaedics in Children – to name a few.
Jo-Anne’s objective has always been to provide the best services to the children that she works with so she opened S.M.I.L.E. Therapy for Kids a private practice that specializes in child development, to meet the demand for all areas of developmental and orthopaedic therapy in children.
She continues to research and find the best treatments for all the children that are under her care and connects with specialists all over the world to achieve this.
Jo-Anne travels to various countries to provide therapy intensives for groups of families who request her services.
Jo-Anne is looking forward to continuing to mentor and train/teach new therapists to become stronger in this field and will carry on traveling and teaching as many people in as many places to help children all over the world.
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