Epidemiology of scoliosis in cerebral palsy: A population-based study at skeletal maturity.

AIM: This study investigated the prevalence of scoliosis in a large, population-based cohort of individuals with cerebral palsy (CP) at skeletal maturity to identify associated risk factors that may inform scoliosis surveillance. METHODS: Young people with CP born between 1990 and 1992 were reviewed through routine orthopaedic review or a transition clinic. Classification of CP was recorded by movement disorder, distribution, gross and fine motor function. Clinical examination was undertaken and those with clinical evidence of scoliosis or risk factors had radiographs of the spine. Scoliosis severity was measured and categorised by Cobb angle. RESULTS: Two hundred and ninety-two individuals were evaluated (78% of the birth cohort) at a mean age of 21 years, 4 months (range 16-29 years). Scoliosis (Cobb angle >10°) was found in 41%, with strong associations to the Gross Motor Function Classification System (GMFCS), Manual Abilities Classification System (MACS) and dystonic/mixed movement disorders. Those at GMFCS V were 23.4 times (95%CI 9.9-55.6) more likely to develop scoliosis than those at GMFCS I. Severe curves (Cobb >40°, 13% of the cohort) were found almost exclusively in those functioning at GMFCS IV and V, and were 18.2 times (95%CI 6.9-48.5) more likely to occur in those with dystonia than those with spasticity. CONCLUSIONS: Scoliosis was very common in young people with CP, with prevalence and severity strongly associated with GMFCS and MACS level and dystonic movement disorder. Severe curves were almost exclusively found in non-ambulant children. Clinical screening for scoliosis should occur for all children with CP, with radiographic surveillance focusing on those functioning at GMFCS IV and V.

More than an X-ray: Experiences and perspectives of parents of children with cerebral palsy when engaging in hip surveillance.

AIM: We explored the experiences of parents of children with cerebral palsy (CP) when engaging in hip surveillance for their child and aimed to identify the barriers and facilitators they encounter. METHODS: We conducted a pragmatic qualitative study through five focus groups conducted with 23 parents and primary care givers of young people with cerebral palsy. A semi-structured topic guide was used to facilitate discussion. Recordings were transcribed verbatim and transcripts analysed using content analysis. RESULTS: Six major categories emerged: (i) hip surveillance is a shared responsibility; (ii) knowledge is empowering; (iii) hip surveillance should be proactive rather than reactive; (iv) consistency and support from health professionals is valuable; (v) good communication is crucial; and (vi) challenges associated with having an X-ray may not be appreciated. Participants made recommendations related to: service model enhancements, information provision and improving both communication and the experience of having an X-ray. CONCLUSION: Despite having a good understanding of the need and importance of hip surveillance for their child, several barriers to parent engagement exist. Findings will inform the implementation of a family-centred model for hip surveillance and may be relevant to those undertaking or planning the implementation of hip surveillance in other areas.

Health professionals' experiences and barriers encountered when implementing hip surveillance for children with cerebral palsy.

AIM: This study aimed to explore health professionals' experiences of implementing hip surveillance for young people with cerebral palsy (CP) and to identify any barriers they encounter. METHODS: A cross-sectional web-based survey of health professionals supporting children with CP was conducted. Responses were analysed through mixed methods. Responses to items presented as ordinal scales were analysed using descriptive statistics, and open-ended responses through a qualitative approach to identify themes. RESULTS: A total of 32 paediatricians, 2 rehabilitation specialists and 50 physiotherapists completed the survey, with respondents working within both hospital- and community-based settings. Barriers most frequently reported were inconsistency in radiology practice and reporting (35%), parent engagement (32%), limited communication between clinicians (31%), lack of clarity in lines of responsibility (27%) and forgetting to undertake surveillance (26%). Four major themes were identified through qualitative analysis: (i) recognition of the importance of clinical guidelines to hip surveillance; (ii) the value of each role in the team around a child; (iii) the challenge of sharing responsibility; and (iv) the importance of communication in facilitating collaboration. CONCLUSIONS: Barriers can be encountered at each phase of the hip surveillance process, but there are also factors that act as facilitators. Locally, the results will inform the development of an enhanced state-wide approach to hip surveillance for all children with CP. The identified barriers do not appear unique to the local context, and the findings may be transferable to other settings. Awareness of the potential barriers and facilitators would be valuable to those implementing hip surveillance in other areas.

Hip health at skeletal maturity: a population-based study of young adults with cerebral palsy.

AIM: We studied 'hip health' in a population-based cohort of adolescents and young adults with cerebral palsy to investigate associations between hip morphology, pain, and gross motor function. METHOD: Ninety-eight young adults (65 males, 33 females) from the birth cohort were identified as having developed hip displacement (migration percentage >30) and were reviewed at a mean age of 18 years 10 months (range 15-24y). Hip morphology was classified using the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS). Severity and frequency of pain were recorded using Likert scales. Gross motor function was classified by the Gross Motor Function Classification System (GMFCS). RESULTS: Hip pain was reported in 72% of participants. Associations were found between pain scores and both hip morphology and GMFCS. Median pain severity score for MCPHCS grades 1 to 4 was 2 (interquartile range [IQR] 1.0-3.0) compared to 7 (IQR 6.0-8.0) for grades 5 and 6 (severe subluxation or dislocation). Hip surveillance and access to surgery were associated with improved hip morphology and less pain. INTERPRETATION: Poor hip morphology at skeletal maturity was associated with high levels of pain. Limited hip surveillance and access to surgery, rather than GMFCS, was associated with poor hip morphology. The majority of young adults who had access to hip surveillance, and preventive and reconstructive surgery, had satisfactory hip morphology at skeletal maturity and less pain.

Australian hip surveillance guidelines for children with cerebral palsy: 5-year review.

AIM: To ensure hip surveillance guidelines reflect current evidence of factors influencing hip displacement in children with cerebral palsy (CP). METHOD: A three-step review process was undertaken: (1) systematic literature review, (2) analysis of hip surveillance databases, and (3) national survey of orthopaedic surgeons managing hip displacement in children with CP. RESULTS: Fifteen articles were included in the systematic review. Quantitative analysis was not possible. Qualitative review indicated hip surveillance programmes have decreased the incidence of hip dislocation in populations with CP. The Gross Motor Function Classification System was confirmed as the best indicator of risk for displacement, and evidence was found of hip displacement occurring at younger ages and in young adulthood. Femoral geometry, pelvic obliquity, and scoliosis were linked to progression of hip displacement. A combined data pool of 3366 children from Australian hip surveillance databases supported the effectiveness of the 2008 Consensus Statement to identify hip displacement early. The survey of orthopaedic surgeons supported findings of the systematic review and database analyses. INTERPRETATION: This review rationalized changes to the revised and renamed Australian Hip Surveillance Guidelines for Children with Cerebral Palsy 2014, informing frequency of radiographic examination in lower risk groups and continuation of surveillance into adulthood for adolescents with identified risk factors.

Efficacy of partial body weight-supported treadmill training compared with overground walking practice for children with cerebral palsy: a randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of 9 weeks of twice-weekly partial body weight-supported treadmill training (PBWSTT) for children with cerebral palsy (CP) and moderate to severe walking difficulty compared with overground walking. DESIGN: Randomized controlled trial. SETTING: Metropolitan Specialist School for children with moderate to severe physical and/or intellectual disabilities. PARTICIPANTS: Thirty-four children classified level III or IV by the Gross Motor Function Classification System were recruited and randomly allocated to experimental or control groups. Of these, 26 (15 girls, 11 boys; mean age 10 y, 10 mo +/- 3 y, 11 mo [range, 5-18 y]) completed training and testing. INTERVENTIONS: Both groups completed 9 weeks of twice-weekly walking training. The experimental group completed PBWSTT, and the control group completed overground walking practice. MAIN OUTCOME MEASURES: Ten-meter walk test (self-selected walking speed), 10-minute walk (walking endurance), School Function Assessment. RESULTS: The overground walking group showed a trend for an increase in the distance walked over 10 minutes (F=3.004, P=.097). There was no statistically significant difference in self-selected walking speed over 10 meters or in walking function in the school environment as measured by the School Function Assessment. CONCLUSIONS: PBWSTT is safe and feasible to implement in a special school setting; however, it may be no more effective than overground walking for improving walking speed and endurance for children with CP. Continued emphasis on progressive reduction of body weight support along with adding concurrent overground walking practice to a treadmill training protocol may increase the intensity of training and assist with carryover of improvements to overground walking. Treadmill training programs that include concurrent overground walking as an additional key feature of the training protocol need to be rigorously evaluated for children with CP.

A systematic review of the effectiveness of treadmill training for children with cerebral palsy.

PURPOSE: The development of efficient and independent walking is an important therapeutic goal for many children with cerebral palsy (CP). Consequently, there has been growing interest in determining the effects of treadmill training programs for these children. METHOD: A systematic review of the literature was conducted to evaluate the effectiveness of treadmill training for children with CP. Relevant trials were identified by searching electronic databases and by citation tracking. RESULTS: Of 125 papers initially identified, five met the criteria for review. Results showed that treadmill training is safe and feasible for children with CP across a wide range of ages and functional abilities. Children with more severely affected walking ability significantly increased their walking speed (d = 1.48, 95% CI: 0.49-2.40) and gross motor performance (d = 1.5, 95% CI: 0.50-2.50) after training. However, the results also suggested that treadmill speed and length of training sessions might need to be set to specifically match desired intervention goals such as increasing walking speed or endurance. CONCLUSIONS: The review suggests that treadmill training is safe and feasible for children with CP and indicates that there may be some positive benefits in walking speed over short distances and in general gross motor skills. The provision of PBWS may be particularly beneficial for children with more severe walking disability (GMFCS III and IV). Further research is necessary before it can be concluded that treadmill training is beneficial for children with CP.