hip subluxation and dislocation in cp
TRANSCRIPT
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Physiother. Res. Int . 14: 116127 (2009)
Copyright 2009 John Wiley & Sons, Ltd DOI: 10.1002/pri
Physiotherapy Research International
Physiother. Res. Int. 14(2): 116127 (2009)
Published online 4 February 2009 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/pri.434
116
Hip subluxation and dislocation incerebral palsy a prospective study
on the effectiveness of postural
management programmes
TERESA E. POUNTNEY, Chailey Heritage Clinical Services, North Chailey, East Sussex
BN8 4JN, UK
ANNE MANDY, University of Brighton, Mithras House, Lewes Road, Brighton BN2 4AT,
UK
ELIZABETH GREEN, Chailey Heritage Clinical Services, North Chailey, East Sussex,
BN8 4JN, UK
PAUL R. GARD, Pharmacology and Therapeutics Division, University of Brighton, Mithras
House, Lewes Road, Brighton BN2 4AT, UK
ABSTRACT Background and Purpose. Hip subluxation and dislocation are common
sequelae in children with bilateral cerebral palsy and are currently managed by surgical
interventions. This study aimed to investigate the effectiveness of early postural manage-
ment programmes on hip subluxation and dislocation at five years, and the need for treat-
ment in children with bilateral cerebral palsy, and to compare these findings with a
historical control group. Methods. A prospective cohort study followed 39 children who
commenced using postural management equipment under 18 months of age. Levels of
ability, type and amount of equipment use and treatments were recorded every three
months. At 30 and 60 months, the hips were X-rayed and the hip migration percentage was
measured. The results were compared with the historical control group. Results. Childrenwho used equipment at recommended and moderate levels had significantly less chance of
both hips being subluxed than those using equipment at minimal levels (two-tailed Fishers
exactc2p= 0.024).The frequency of children with hip problems was significantly less inthe intervention group in comparison to the historical control group at five years (c2=
11.53, df= 2,p= 0.006). The frequency of children receiving bilateral or unilateral treat-
ments, i.e. surgery, use of a hip and spinal orthosis and/or botulinum toxin injections, in
the intervention group was significantly less compared to the historical control group (two-
tailed Fishers exactp= 0.001). Conclusion. The early provision of postural management
equipment has a role to play in reducing the number of hip problems and therefore the
need for treatment of hip subluxation/dislocation in cerebral palsy at five years of age.
Copyright 2009 John Wiley & Sons, Ltd.
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Effectiveness of postural management programmes
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Key words: cerebral palsy, hip dislocation, postural management programmes
(Reimers, 1980; Turker and Lee, 2000). Areview of the literature on adductor releases
for hip subluxation and their effectiveness in
reducing pain, improving personal care,
increasing range of motion, improving sitting
or preventing pelvic obliquity was limited
because of poorly designed studies (Stott
et al., 2004). This review identified particu-
lar difficulties related to the heterogeneity of
the participants and the variability in surgi-
cal interventions. Further studies are needed
to determine which surgical approaches aremost effective.
A prevention programme involving 206
children with cerebral palsy reported that at
five years, none had developed hip disloca-
tion (Hagglund et al., 2005). However, this
heterogeneous group of children with cere-
bral palsy, of whom only a proportion was
non-ambulant, had an extensive programme
of surgery including soft tissue or bony
surgery, selective dorsal rhizotomies and
intrathecal baclofen. The outcomes of surgi-cal intervention are not always successful in
controlling further progression to disloca-
tion in the long term (Miller and Bagg, 1992;
Young et al., 2001; Pountney et al., 2002).
Adolescents and adults have reported pain at
surgical sites, which persists over many
years (Schwartz et al., 1999; Hodgkinson
et al., 2001).
Other less invasive approaches to the
management of hip subluxation have become
popular over the past 10 years, particularlythe use of postural management equipment.
This approach offers a planned programme
of activities and interventions to control an
individuals posture and function. Postural
management equipment offers positioning
in lying, sitting and standing to encourage
BACKGROUND
Hip subluxation and dislocation are common
sequelae in children with bilateral cerebral
palsy and have a debilitating effect on func-
tion, pain, ability to sit and personal care
(Cooperman et al., 1987; Cornell, 1995).
High rates of subluxation and dislocation
were reported in children not walking
independently (Scrutton and Baird, 1997;
Scrutton et al., 2001; Morton et al., 2006;
Soo et al., 2006). A population study moni-toring hip development in children with cere-
bral palsy found that at five years of age, 54%
of children not walking independently had
one or both hips subluxed or had treatment
for their hips (Scrutton and Baird, 1997;
Scrutton et al., 2001). Scrutton and Baird
described children as having a hip problem
if they had either surgery or botulinum toxin
A injection to the muscles surrounding the
hips or a hip and spinal orthosis (HASO)
and/or a migration percentage of>32% byfive years of age. Of children not walking at
five years, 38.1% had both hips affected and
15.8% had unilateral problems. Soo et al.
(2006) reported that at Gross Motor Function
Classification System (GMFCS) Levels IV
and V, rates of hip displacement were 69%
and 90%, respectively (Palisano et al., 1997).
These figures indicate that there are high
rates of subluxation and dislocation, which
continue to increase into adolescence impact-
ing on functional ability, pain and a need toaddress the prevention of hip subluxation
(Miller and Bagg, 1992).
To date, hip subluxation and dislocation
have been largely treated by surgical inter-
ventions, which include preventative soft
tissue and reconstructive bony surgery
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active movement, maintain muscle length,
control/prevent deformity and increase
function (Gericke, 2006). Chailey Heritage
Clinical Services has developed a range of
postural management equipment to supportchildren in postures which simulate a higher
functional ability (Pountney et al., 2004).
Some evidence to support this approach in
controlling hip migration in the form of
cohort studies is available (Hankinson and
Morton, 2002; Pountney et al., 2002). A ret-
rospective study of 60 children found that
children with cerebral palsy using postural
management equipment in lying, sitting and
standing before hip subluxation occurred
were significantly more likely to maintainhip integrity than children who did not use
the full range of equipment or used it after
hip subluxation had occurred (Pountney
et al., 2002). The use of a sleep system
with children positioned in supine and a hip
abduction of 20 bilaterally found a signifi-
cant decrease in hip migration percentage
over one year (Hankinson and Morton,
2002).
The evidence for different approaches to
the management of hip subluxation/disloca-tion is not conclusive with only limited
robust evidence for the use of surgical inter-
ventions and postural management equip-
ment to control hip dislocation. Further
research is required to determine the most
effective approaches to prevent and manage
hip subluxation. In this study, the focus will
be on the effectiveness of early provision
postural management equipment to prevent
hip subluxation and dislocation.
METHODS
This a prospective longitudinal cohort design
study following the progress of children
with cerebral palsy up to five years of age
compared with a subset of a historical control
group of children with cerebral palsy. The
historical control group was created from a
population study in the South East of England
monitoring hip development using serial X-
ray measurements from age 18 to 60 months.A subset of this study (n= 202) who were
not walking at five years will be used to
determine the effect of the therapeutic inter-
vention, postural management equipment,
for comparison in this study (Scrutton and
Baird, 1997; Scrutton et al., 2001). The
control group was drawn from the same
geographic population, and therefore other
aspects of the childrens treatment were
likely to be similar, improving the validity
of the study. The researcher has been allowedaccess to the raw data on the subset of
children not walking independently from
Scrutton and Bairds study from their 2001
paper to compare findings with the inter-
vention group using postural management
programmes.
Ethical approval was given by the East
Sussex, Brighton and Hove Local Research
Ethics Committee. The conditions have been
adhered to and an informed consent for par-
ticipation and publication has been obtainedfrom the parents of all children taking part
in the study.
Participants
Children were recruited from child develop-
ment centres and acute hospital trusts in the
South Thames Health Region of England.
Inclusion criteria (prospective)
Children with a diagnosis of bilateral cere-
bral palsy who were aged 18 months or less
(18 months was chosen as, at this stage, dif-
ferences in hip development become statisti-
cally apparent [Scrutton et al., 2001] and
allowed time for postural management
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equipment to be effective); no other condi-
tion likely to affect their musculoskeletal
development at referral to the study; and
children not walking independently by five
years of age.
Inclusion criteria (historical)
The subset of the historical control group not
walking independently at five years of age.
Hip migration percentage
Hip migration percentage is a reliable and
repeatable method of determining the degree
of subluxation or dislocation of the hip joint(see Figure 1) (Reimers, 1980; Parrott et al.,
2002; Pountney et al., 2003). It measures the
percentage of the bony femoral head, which
lies outside the lateral border of the acetabu-
lum on an anteroposterior X-ray. Hip and
pelvic positions at X-ray needs to be consis-
tent to ensure that sequential X-rays offer
reliable data on changes in hip migration (see
Figure 2) (Reimers and Bialik, 1981; Scrut-
ton and Baird, 1997). The definitions chosen
to describe hip subluxation and dislocationwere those of Cooperman et al. (1987), who
considered a hip to be subluxed if migration
percentage is between 33% and 80%, and
dislocated if 80% or greater. The use of a
minus migration percentage was not advo-
cated as it may not provide a true measure
of migration either because of a poorly devel-
oped epiphysis or an excessive change in
migration following ossification (Scrutton
et al., 2001). Minus migration percentages
will therefore be recorded from 0%.
Equipment
The Chailey postural management equip-
ment used provided consistent positioning of
the hip and pelvis in lying, sitting and stand-
ing (Green and Nelham, 1991; Green et al.,
1993; Pountney et al., 2004). In lying, the
child was positioned in supine or prone with
hip abduction of 20 and lateral supports for
the pelvis and trunk. In sitting, the child waspositioned with a neutral position of the
pelvis (tilt, rotation and obliquity) and of the
hips (abduction and rotation). In the stand-
ing support, the child was positioned in an
upright position with a 10 forward lean at
the hips to allow functional activity (see
Figures 35). The rates of compliance of the
children using the equipment were rated as
recommended, moderate or minimal based
on a childs age and Chailey level of ability.
FIGURE 1: Measurement of the hip migration
percentage and acetabular index.
FIGURE 2: (a) The standard position for an antero-
posterior X-ray and (b) the adapted position for the
child with tight hamstrings to control posterior pelvic
tilt.
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These data were collected by questionnaire
at the three monthly reviews. These levels
were taken from a previous retrospective
study, which categorized use into three cat-
egories according to the degree of postural
control required and the length of time used
(Pountney et al., 2002). Recommended useby five years of age, a child at Chailey level
2 (supine) was to use a lying support at
night, a seating system for approximately six
hours per day and a standing support for one
hour per day. A moderate use was the use of
two items of equipment for a minimum of
six hours per day; a minimal use was the use
of one or no items of equipment. The length
of time of use would also be a factor, e.g.
having two items of equipment but using
them less than six hours a day would berated minimal.
Procedure
Clinicians identified children who met
the inclusion criteria for the study. An
FIGURE 3: Supine lying support.
FIGURE 4: CAPS 11 Seating System.
FIGURE 5: Chailey standing support.
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information sheet was sent to the clinician
for the parents to read and discuss together,
and an informed consent was obtained by
the researcher. The initial assessment
included relevant past and present medicalhistory, medications, current equipment,
Chailey levels of ability, current treatments
and issues affecting equipment provision,
e.g. sleep patterns and reflux. The childs
postural management requirements were
discussed with the parents and local thera-
pist, and were prescribed and fitted accord-
ing to each childs clinical need.
The children were reviewed on a three
monthly basis: the Chailey levels of ability
were recorded, the equipment was adjustedand updated, and a questionnaire was com-
pleted by the researcher or the parents detail-
ing which equipment the child used and the
amount of time spent in the equipment in the
previous three months. Other relevant infor-
mation relating to a childs physical develop-
ment was recorded. At five years of age,
each child was classified on the GMFCS
(Palisano et al., 1997).
At 30 months and five years of age, the
childs paediatrician was approached torequest a hip and pelvic X-ray. Information
regarding positioning for the X-ray was sent
to the radiography departments. X-rays were
obtained and measured, and hip status was
categorized as both hips safe, i.e. under 33%,
one or both hips subluxed.
RESULTS
Fifty-two children were recruited to the
study from health authorities in East andWest Sussex, Kent, Surrey and London.
Thirteen children withdrew from the study:
seven died (a reflection of the severity of
their impairment and age), one for social
reasons, one had developmental dysplasia of
the hips, one had the diagnosis changed to
hemiplegia, two had on going ill health, and
one child walked by age five. Thirty-nine
children were therefore included in this anal-
ysis, 23 boys and 16 girls. Appendix 1 shows
the characteristics of the sample: GMFCS,distribution of cerebral palsy, equipment
provision, treatments and percentage hip
migration. No data on the GMFCS in the
historical control group were available as
they were not in use at this time; however,
all children were not walking at five years
and therefore would have been classified at
levels IIIV.
Chailey levels of ability
The Chailey level of abilities in supine at 30
months ranged from levels 2 to 6, with 17
children (43.6%) at level 2 (unable to main-
tain symmetry in supine) and 9 children
(23.1%) at level 6 (able to roll and use hands
in midline). By 60 months of age, 21 chil-
dren (55.3%) were at level 2 in lying, and a
further 2 (28.9%) had reached level 6.
Postural management
equipment provision and use inthe intervention group
The range of postural management equip-
ment provided at 30 months and five years
of age included combinations of lying, stand-
ing and seating supports, and is shown in
Table 1.
Data on the use of equipment were col-
lected from the questionnaires completed at
each review point. The level of use at 30 and
60 months was averaged and categorized asrecommended, moderate or minimal use
(see Table 2).
A Fishers exact test was used to compare
the use of equipment and hip status. At five
years, there was a higher frequency of chil-
dren with both hips not subluxed (
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migrated) using the equipment at recom-
mended or moderate levels than those using
the equipment at minimal amounts (two-tailed Fishers exact 2p= 0.024).
Migration percentage at 30 months and
five years in the historical control and
intervention groups
In the intervention group, the age range
at which the 30-month X-ray was taken
extended from two to four years with a mean
age of 2.6 years. For the five-year X-ray, the
mean age was 5.1 (range 4.15.8) years. Thiswas because of X-rays being taken prior to
request and further exposure to radiation
was not justified, difficulties in organizing
X-rays or non-attendance. All X-rays were
valid for measurement, except for two, which
had an excessive adduction on the left side.
There were no significant differences among
the migration percentage between the his-
torical control and intervention groups at 60months. Table 3 shows the mean and range
of migration percentage at 30 and 60
months.
Migration percentages for both of a
childs hips are reported at five years. In the
intervention group, 59% of the children had
both hips migrated less than 33%, and 41%
had migration percentages greater than 33%
in at least one hip. In the historical control
group, 50% of the children had both hips
migrated less than 33%, and 41% had migra-tion percentages greater than 33% in at least
one hip. In the historical control group, 15%
of the data were categorized as missing data
and were described as either no available
X-ray or no measurement acceptable from
an X-ray.
TABLE 1: Equipment provision at 30 months and five years
Equipment Lying, seat ing and
standing support
Lying and
seating support
Seating and
standing support
Seating only Other
30 months 22 (56.4%) 2 (5.1%) 14 (35.9%) 0 (0%) 1 (2.6%)Five years 15 (38.4%) 0 16 (41%) 4 (10.3%) 4 (10.3%)
TABLE 2: Averaged use of equipment at 30 months and five years
Average use to
30 months and five years
Recommended
number (%)
Moderate
number (%)
Minimal
number (%)
30 months 22 (56.4%) 10 (25.6%) 7 (17.9%)Five years 11 (28.2%) 22 (56.4%) 6 (15.4%)
TABLE 3: Mean and range of migration measures at 30 and 60 months
Hip side and mo nths Intervention (mean and range) Historical control (mean and range)
Right, 30 17.6 (056) 20.7 (081)Left, 30 22.6 (061) 19.7 (087)Right, 60 25.9 (077) 28 (0100)Left, 60 30.4 (0100) 26.2 (0100)
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Comparison of hip problems at five
years between the control and
intervention groups
At five years of age, the intervention groupwas compared with a subset (n = 202) of
the historical control group of children not
walking at five years defined as follows:
had hip surgery and/or botulinum toxin
A injection for the hips;
had been prescribed a HASO by an
orthopaedic surgeon; and/or
having a hip migration percentage >32%
(Scrutton and Baird, 1997; Scrutton
et al., 2001).
Table 4 shows the comparison between
the subset of the historical control group not
walking at five years (Scrutton et al., 2001)
and the intervention group. In the historical
control group of children who were not
walking independently at five years, 38.5%
had a bilateral hip problem and 15.5% had a
unilateral problem. In the intervention group,
10.3% had a bilateral problem and 25.6%
had a unilateral problem. Although unilat-eral problems were greater in the interven-
tion group, overall there was an 18.2%
reduction in hip problems. There was a sig-
nificant difference between the observed
and expected frequencies of children in the
historical control and intervention groups
with hip problems. Children in the interven-
tion group were significantly less likely to
have hip problems (2 = 11.53, df = 2,
p = 0.006).
Treatment for hip problems
Table 5 shows the frequency of children
having bilateral and unilateral treatments,
i.e. surgery, use of a HASO and/or botuli-
num toxin injections, in both the historical
control and intervention groups. Signifi-
cantly less children in the intervention group
received bilateral or unilateral treatment,
and significantly more had no treatment(two-tailed Fishers exactp= 0.001).
Table 6 shows the frequency and type of
treatments of children in the historical
control and intervention groups. Surgical
treatment was reduced from 46% in the
control group to 5.1% in the intervention
group. No children in the intervention
group used a HASO but three children
received botulinum toxin injections into the
muscles surrounding the hip. There was a
significant difference between the observedand expected frequency of children in the
historical control and intervention groups
having surgical interventions. Children in
the intervention group were significantly
less likely to have a hip surgery (2 =
11.5322.91, df= 1,p 0.001).
TABLE 4: Frequency of bilateral and unilateral
problems in the historical control and intervention
groups
Group Historical
control
Intervention
Bilateral problem 77 (38.1%) 4 (10.3%)Unilateral problem 32 (15.8%) 10 (25.6%)No problem 93 (46.1%) 25 (64.1%)Total 202 (100%) 39 (100%)
TABLE 5: Treatment for bilateral and unilateral
problems
Treatment Control Intervention
Bilateral problem 65 (32.2%) 5 (13%)Unilateral 37 (18.3%) 0 (0%)No treatment 98 (48.5%) 34 (87%)Missing cases 2 (1%) 0 (0%)Total 202 (100%) 39 (100%)
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DISCUSSION
These findings indicate that children usingpostural management equipment up to the
age of five years at recommended or moder-
ate levels had a significantly greater chance
of both hips being less than 33% migrated
at five years. Equipment use involves an
ongoing commitment by families, carers,
teachers and clinicians, and the length of the
study, over five years, meant that the use of
equipment at times was somewhat variable
because of illness and social/family situa-
tions. Moderate use appears to be sufficientto show a difference in outcomes; however,
this has not been precisely quantified.
The historical group had a substantial
number of missing data on migration per-
centage either because of a lack of X-ray or
an unacceptable measurement. This number
is likely to include hips, which could not be
measured because of hip and pelvic posi-
tions and may have had a confounding effect
on the comparison between the historical
control group and the intervention group.The lying support was the least used item
of equipment, with the majority of children
using the seating and standing supports,
which offer a more functional and inclusive
position for activity. Many children with
cerebral palsy have sleep problems including
the risk of reflux and respiratory problems
(Khan and Underhill, 2006). This may have
impacted on the families reluctance to inter-fere with a childs sleep routine, which might
cause an increased risk of night-time distur-
bance. The use of a lying support dropped
between 30 and 60 months with nine fewer
children using the support and is comparable
with clinical practice.
Recent work by Soo et al. (2006), which
found children at levels IV and V on the
GMFCS, had hip subluxation rates of 69%
and 90%, respectively, at a mean age of 11.7
years. Rates of displacement in the interven-tion group at levels IV and V were 10% and
23% at five years, and this cohort will be
followed to see if these levels are sustained
over time in this cohort.
Treatment, particularly surgery, in the
intervention group was reduced compared
with that of the historical control group
without an increase in hip migration per-
centage. Over the period of the study, there
have been changes in orthopaedic practice
away from early soft tissue hip surgery;however, the large reduction is unlikely to
be entirely due to change in practice. The
findings on use and migration percentage
suggest that postural management equip-
ment is a factor in this reduction. These
findings contrast with the findings of the
TABLE 6: Comparison of treatment for hip problems in the control and intervention groups
Treatment Control group
(number of children)
Intervention group
(number of children)
Surgery 93 (46%) 2 (5.1%)Hip orthosis 48 (23.7%0 0 (0%)Botulinum toxin injections 0 (0%) 6 (15.4%)No treatment but >32% 55 (27.2%) 22 (56.4%)No treatment 6 (3%) 9 (23.1%)Total 202 (100%) 39 (100%)
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Hagglund et al. (2005) study where surgery
was the main intervention for hip dysplasia
under five years.
The reduction in bilateral hip problems
may reflect the position that the childrenadopted in the equipment, i.e. controlling a
childs hip and pelvis in neutral tilt, obliquity
and rotation, and the hips in neutral ab/
adduction and rotation. Applying forces to
reduce asymmetry, the hip and pelvic posi-
tions may lead to improved hip outcomes
and have a protective effect for spinal cur-
vature, but comparative studies are needed
to determine this.
This study has focused on its role in the
management of hip subluxation and suggeststhat the use of postural management equip-
ment can play a role in the management
of deformity besides the accepted role of
improved postural control for functional
activities (Pountney and Green, 2006).
Further research is required in the man-
agement of hip dislocation in children with
cerebral palsy, both for early intervention
and in terms of long-term outcomes. Migra-
tion percentage alone may not indicate a
need for treatment but should be set in thecontext of a childs pain and function or the
postural effect on the spine. The views of
children and their families on these inter-
ventions need to be sought as different inter-
ventions can affect the quality of life.
Combinations of different approaches, such
as postural management equipment, botuli-
num toxin injections and surgery, may
achieve long-term successful outcomes but
requires collaborative working to maximize
outcomes.Limitations of the study included the use
of a historical control group, which intro-
duced, particularly, changes in surgical
practice; the size of the cohort; and con-
founding variables, which could not be
controlled within the family setting.
This study suggests that the use of pos-
tural management equipment in hip man-
agement could reduce levels of subluxation
and consequent surgery if introduced early
and if used at recommended and moderateamounts. Recommendations would be in
line with a consensus statement on the use
of postural management programmes, which
includes provision of postural management
equipment at the earliest stages particularly
in children at levels IV and V on the GFMCS
(Gericke, 2006).
CONCLUSION
The early provision of postural managementequipment has a role to play in reducing the
levels of hip problems and therefore the need
for treatment for hip subluxation/dislocation
in children with cerebral palsy at five years.
However, there is a continuing risk of hip
subluxation into adolescence, and influences
affecting the long-term outcomes of inter-
ventions need to be determined.
ACKNOWLEDGEMENTS
This study was funded by the Action Medical Research,the Mrit and Hans Rausing Charitable Foundation,
Rosetrees Trust, and other trusts and foundations who
wish to remain anonymous.
The authors thank David Scrutton for his support
and generosity in sharing his original data.
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Address correspondence to: Teresa E. Pountney,
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East Sussex BN8 4JN, UK (E-mail: Terry.
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(Submitted April 2008; accepted October 2008)
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