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 is 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 anteversion 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 orthopedic 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 AFOs)
- 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 on 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 orthopedic 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.
We want to wrap up by extending our gratitude to thank you for stopping by today!
What is your experience with hip dysplasia?
Let us know in the comments below. ♥
Was this information helpful to you? If so, you’d make our day by sharing it. 🙂
- Blake SF, Logan S, Humphreys G, Matthews J, Rogers M, Thompson-Coon J, Wyatt K, Morris C. (2015). Sleep positioning systems for children with cerebral palsy. Cochrane Database of Systematic Reviews, (Issue 11)
- Bax, M., Goldstein M., Rosenbaum, P., & Leviton, A. (2005). Proposed definition and classification of cerebral palsy, April 2005. Developmental Medicine and Child Neurology, 47(8), 571-576.
- Boyd, R. N., Dobson, F., Parrott, J., Love, S., Oates, J., Larson, A., … Graham, H. K. (2001). The effect of botulinum toxin type A and a variable hip abduction orthosis on gross motor function: A randomized controlled trial. European Journal of Neurology, 8(s5), 109-119. doi:10.1046/j. 1468-1331.2001.00043.x
- Dalen, Y., Sf, M., Ringertz, H., & Klrfbeck, B. (12). Effects of standing on bone density and hip dislocation in children with severe cerebral palsy. Advances in Physiotherapy, 12(4), 187-193.
- Deleplanque, B., Lagueny, A., Flurin, V., Arnaud, C., Pedespan, J.M., Fontan, D., & Pontallier, J.R. (2002). Botulinum toxin in the management of spastic hip adductors in non-ambulatory cerebral palsy children. Revue De Chirurgie Orthopedique Et Reparatrice De L’Appareil Moteur, 88(3), 279-285.
- DiFazio, R., Vessey, J.A., Miller, P., Van Nostrand, K., & Snyder, B. (2016). Postoperative complications after hip surgery in patients with cerebral palsy: A retrospective matched cohort study. Journal of Pediatric Orthopaedics, 36(1), 56-62.
- Evans, G.A. (1995). (iii) The lower limb in cerebral palsy. Current Orthopaedics, 9(3), 156-163.
- Gmelig Meyling, C., Ketelaar, M., Kuijper, M., Voorman, J., & Buizer, A. I. (2018). Effects of postural management on hip migration in children with cerebral palsy: A systematic review. Pediatric Physical Therapy: The Official Publication of the Section on Pediatrics of the American Physical Therapy Association, 30(2), 82-91. doi:10.1097/PEP. 0000000000000488 1
- Graham, H.K., Boyd, R., Carlin, J.B., Dobson, F., Lowe, K., Nattrass, G., … Reddihough, D. (2008). Does botulinum toxin combined with bracing prevent hip displacement in children with cerebral palsy and “hips at risk”? A randomized, controlled trial. Journal of Bone & Joint Surgery, American Volume, 90(1), 23-33. doi:10.2106/JBJS.F.01416
- Hankinson, J., & Morton, R.E. (2002). Use of a lying hip abduction system in children with bilateral cerebral palsy: A pilot study. Developmental Medicine and Child Neurology, 44(3), 177-180. doi:10.1017/S001216220100189X
- Hill, S., & Goldsmith, J. (2010). Biomechanics and prevention of body shape distortion. Tizard Learning Disability Review, 15(2), 15.
- Htwe, O., Ismail, F., Leonard, H.J., & Amaramalar, S.N. (2016). Hip subluxation/dislocation in children with cerebral palsy: Does standing help? International Medical Journal, 23(2), 169-172.
- Jozwiak, M., Harasymczuk, P., & Ciemniewska-Ggorzela, K. (2007). [The use of botulinum toxin in the treatment of spastic hip joint instability in children with cerebral palsy]. Chirurgia Narzadow Ruchu i Ortopedia Polska, 72(3), 205-209.
- Jung, N.H., Heinen, F., Westhoff, B., Doederlein, L., Reissig, A., Berweck, S., … Mall, V. (2011). Hip lateralisation in children with bilateral spastic cerebral palsy treated with botulinum toxin type A: A 2-year follow-up. Neuropediatrics, 42(1), 18-23. doi:10.1055/s-0031-1275344
- Jung, N.H., Pereira, B., Nehring, I., Brix, O., Bernius, P., Schroeder, S.A., … Mall, V. (2014). Does hip displacement influence health-related quality of life in children with cerebral palsy? Developmental Neurorehabilitation, 17(6), 420-425. doi:10.3109/17518423.2014.941116
- Kim, I.S., Park, D., Ko, J.Y., & Ryu, J.S. (2019). Are seating systems with a medial knee support really helpful for hip displacement in children with spastic cerebral palsy GMFCS IV and V? Archives of Physical Medicine and Rehabilitation, 100(2), 247-253. doi:10.1016/j.apmr.2018.07.423
- Kim, M.O., Lee, J.H., Yu, J.Y., An, P.S., Hur, D.H., Park, E.S., & Kim, J.H. (2013). Changes of musculoskeletal deformity in severely disabled children using the custom molded fitting chair. Annals of Rehabilitation Medicine, 37(1), 33.
- Kirkwood, C., & Bardsley, G.I. (2001). Seating and positioning in spasticity. Cambridge, Cambridge University Press
- Macias-Merlo, L., Bague-Calafat, C., Girabent-Farres, M., & A Stuberg, W. (2016). Effects of the standing program with hip abduction on hip acetabular development in children with spastic diplegia cerebral palsy. Disability & Rehabilitation, 38(11), 1075-1081.
- Martinsson, C., & Himmelmann, K. (2011). Effect of weight-bearing in abduction and extension on hip stability in children with cerebral palsy. Pediatric Physical Therapy, 23(2), 150-157.
- Miller, S.D., Juricic, M., Hesketh, K., Mclean, L., Magnuson, S., Gasior, S., … Mulprui, K. (2017). Prevention of hip displacement in children with cerebral palsy: A systematic review. Developmental Medicine & Child Neurology, 59(11), 1130-1138. doi:10.1111/dmcn.13480
- Palisano, R., Rosenbaum, P., Walter, S., Russell, D., Wood, E., & Galuppi, B. (1997). Development and reliability of a system to classify gross motor function in children with cerebral palsy. Developmental Medicine & Child Neurology, 39(4), 214-223.
- Park, E.S., Rha, D., Lee, W.C., & Sim, E.G. (2014). The effect of obturator nerve block on hip lateralization in low functioning children with spastic cerebral palsy. Yonsei Medical Journal, 55(1), 191-196. doi:10.3349/ymj.2014.55.1.191
- Pavlik, A., & Pelitier, L.F. (1992). The functional method of treatment using a harness with stirrups as the primary method of conservative therapy for infants with congenital dislocation of the hip. Clinical Orthopaedics and Related Research, 281, 4-10.
- Picciolini, O., Albisetti, W., Cozzaglio, M., Spreafico, F., Mosca, F., & Gasparroni, V. (2009). “Postural Management” to prevent hip dislocation in children with cerebral palsy. Hip International, 19(6_suppl), 56-62.
- Picciolini, O., LE Metayer, M., Consonni, D., Cozzaglio, M., Porro, M., Gasparroni, V., … Portinaro, N.M. (2016). Can we prevent hip dislocation in children with cerebral palsy? effects of postural management. European Journal of Physical & Rehabilitation Medicine, 52(5), 682-690.
- Pidcock, F.S., Fish, D.E., Johnson-Greene, D., Borras, I., McGready, J., & Silberstein, C.E. (2005). Hip migration percentage in children with cerebral palsy treated with botulinum toxin type A. Archives of Physical Medicine & Rehabilitation, 86(3), 431-435.
- Placzek, R., Deuretzbacher, G., & Meiss, A.L. (2004). Treatment of lateralisation and subluxation of the hip in cerebral palsy with botulinum toxin A: Preliminary results based on the analysis of migration percentage data. Neuropediatrics, 35(01), 6-9. doi:10/1055/s-2003-43549
- Pountney, T.E., Mandy, A., Green, E., & Gard, P.R. (2009). Hip subluxation and dislocation in cerebral palsy – a prospective study on the effectiveness of postural management programs. Physiotherapy Research International: The Journal for Researchers and Clinicians in Physical Therapy, 14(2), 116-127. doi:10.1002/pri.434
- Pountney, R., Mandy, A., Green, E., &Gard, P. (2002). Management of hip dislocation with postural management. Child: Care, Health and Development, 28(2), 179-185. doi:10.1046/j. 1365-2214.2002.00254.x
- Ramstad, K., Jahnsen, R.B., & Terjesen, T. (2017). Severe hip displacement reduces health-related quality of life in children with cerebral palsy. Acta Orthopaedica, 88(2), 205-210. doi:10.1080/17453674.2016.1262685
- Reimers, J. (1980). The stability of the hip in children: A radiological study of the results of muscle surgery in cerebral palsy. Acta Orthopaedica Scandinavica, 51(84), 1-100, doi:10.3109/ort.1980.51.suppl-184.01
- Shore, B., Spence, D., & Graham, H.K. (2012). The role for hip surveillance in children with cerebral palsy. Current Reviews in Musculoskeletal Medicine, 5(2), 126-134. doi:10.1007/s12178-012-9120-4
- Willoughby, K., Jachno, K., Ang, S.G., Thomason, P., & Graham, H.K. (2013). The impact of complementary and alternative medicine on hip development in children with cerebral palsy. Developmental Medicine & Child Neurology, 55(5), 472-479. doi:10.1111/dmcn.12094
Affiliate Disclaimer: This post may contain affiliate links for your convenience. Thank you for your ongoing support to keep this website thriving for kids.
The contents of the Intensive Therapy for Kids Site, such as text, graphics, images, and other material contained on the Intensive Therapy for Kids Site (“Content”) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health providers with any questions you may have regarding a medical condition.