Leisure Time Physical Activity in Children and Young People With Cerebral Palsy: A Population-Based Study.

PURPOSE: To describe leisure time physical activity in children and young people with cerebral palsy and identify barriers and facilitators to participation. METHODS: Leisure time physical activity participation was derived from a national cerebral palsy register and associated factors were analyzed. Barriers and facilitators to participation were investigated through a survey. RESULTS: Leisure time physical activity participation was recorded. Outcomes of participation decreased with increasing Gross Motor Function Classification System level. Leisure time physical activity "not in club" for 11- to 18-year-olds was significantly lower than for those aged 5 to 10 years for Gross Motor Function Classification System level II. The survey supported that disability and disliking help were common barriers and parental encouragement and enjoyment were common facilitators. CONCLUSIONS: Data from the register and survey provide insight into factors influencing leisure time physical activity participation in young people with cerebral palsy and how to increase.

Distribution and motor ability of children with cerebral palsy in Scotland: a registry analysis.

BACKGROUND AND AIMS: Cerebral palsy is the commonest long-term physical disability in children with a prevalence of between 1.77 and 2.11/1000 live births. In 2013, the Cerebral Palsy Integrated Pathway Scotland (CPIPS) surveillance programme was introduced in all 14 Health Boards in Scotland and provides a standardised musculoskeletal examination of the spine and lower limbs. The purpose of this study was to report the prevalence, subtypes, motor classification and motor ability of children with cerebral palsy in Scotland. METHODS AND RESULTS: The family/carer's postal address, the child's neurological classification, motor subtypes, Gross Motor Functional Classification (GMFCS) Level and Functional Mobility Scale of 1972 children at first registration in CPIPS 2013-2018 were analysed. Their mean age at first assessment was 7.6 years. There was an overall prevalence of cerebral palsy in Scotland of 2.02/1000. GMFCS levels and Functional Mobility Scale data and prevalence were reported by Health Board and were comparable to that reported elsewhere. CONCLUSION: For the first time, data are available on the motor abilities of the total population of children with cerebral palsy in Scotland. This information will be highly relevant to resource management of current and future motor needs of these children.

How Critical is Patient Positioning in Radiographic Assessment of the Hip in Cerebral Palsy When Measuring Migration Percentage?

BACKGROUND: Migration percentage (MP) is an accepted method of assessing lateral displacement of the femoral head in children with cerebral palsy (CP). Difficulty in positioning of patients for pelvic radiography remains a concern for the reliability of the MP. METHODS: This 2-part quantitative study examined 100 anteroposterior pelvic radiographs for children with CP. Fifty were from a region that had a positioning protocol for hip surveillance of children with CP and 50 images were from a region without. Images were assessed for acceptability of position in relation to hip abduction/adduction and/or pelvic rotation.Ten images deemed Acceptable or Borderline from the region with no protocol were then randomly selected. MP was measured on 2 separate occasions by 5 children's orthopaedic surgeons and statistically analyzed for intrarater and interrater reliability. RESULTS: There was no statistically significant difference in the acceptability of images between the 2 regions with 60% to 66% of the images meeting the criteria outright. When allowances were made for slight variation of abduction/adduction within 5 degrees, 74% to 80% of the images were acceptable.Reliability was variable with limits of agreement between 4.96% and 15.15%. Observers more familiar with the software measuring package had higher reliability within and between occasions. Variability within and between observers decreased as MP increased. CONCLUSIONS: Poor positioning did not appear to be the main reason for the variation in reliability of MP. Repeat measurements were reliable although standardized technique, training, and familiarity with software measuring programmes did influence outcomes.

Validation of a modified Care and Comfort Score and responsiveness to hip surgery in children with cerebral palsy in Gross Motor Function Classification System levels IV and V.

Aims: The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V. Methods: This was a population-based cohort study in children with CP from a national surveillance programme. Reliability was assessed from 20 caregivers who completed the mCCHQ questionnaire on two occasions three weeks apart. Test-retest reliability of the mCCHQ was calculated, and responsiveness before and after surgery for a displaced hip was evaluated in a cohort of children. Results: Test-retest reliability for the overall mCCHQ score was good (intraclass correlation coefficient 0.78), and no dimension demonstrated poor reliability. The surgical intervention cohort comprised ten children who had preoperative and postoperative mCCHQ scores at a minimum of six months postoperatively. The mCCHQ tool demonstrated a significant improvement in overall score from preoperative assessment to six-month postoperative follow-up assessment (p < 0.001). Conclusion: The mCCHQ demonstrated responsiveness to intervention and good test-retest reliability. The mCCHQ is proposed as an outcome tool for use within a national surveillance programme for children with CP.

The CPUP Hip Score predicts displacement of the hip in children with cerebral palsy.

AIMS: The Uppföljningsprogram för cerebral pares (CPUP) Hip Score distinguishes between children with cerebral palsy (CP) at different levels of risk for displacement of the hip. The score was constructed using data from Swedish children with CP, but has not been confirmed in any other population. The aim of this study was to determine the calibration and discriminatory accuracy of this score in children with CP in Scotland. METHODS: This was a total population-based study of children registered with the Cerebral Palsy Integrated Pathway Scotland. Displacement of the hip was defined as a migration percentage (MP) of > 40%. Inclusion criteria were children in Gross Motor Function Classification System (GMFCS) levels III to V. The calibration slope was estimated and Kaplan-Meier curves produced for five strata of CPUP scores to compare the observed with the predicted risk of displacement of the hip at five years. For discriminatory accuracy, the time-dependent area under the receiver operating characteristic curve (AUC) was estimated. In order to analyze differences in the performance of the score between cohorts, score weights, and subsequently the AUC, were re-estimated using the variables of the original score: the child's age at the first examination, GMFCS level, head shaft angle, and MP of the worst hip in a logistic regression with imputation of outcomes for those with incomplete follow-up. RESULTS: The discriminatory accuracy of the score in the new population of 367 children was high (AUC 0.78 (95% confidence interval (CI) 0.71 to 0.86)). The calibration of the score was insufficient (slope 0.48 (95% CI 0.31 to 0.65)), and the absolute risks of displacement of the hip in this population were overestimated. The AUC increased with re-estimated weights (0.85 (95% CI 0.79 to 0.91)). CONCLUSION: The CPUP Hip Score had a high ability to discriminate between children at different levels of risk for displacement of the hip. The score overestimated the absolute risks of displacement in this population, which may have resulted from differences in the way children were initially registered in the two programmes. The results are promising, but the score weights may need re-estimation before its clinical application in Scotland. Cite this article: Bone Joint J 2022;104-B(5):640-644.

Hip displacement in children with cerebral palsy.

AIMS: The migration percentage (MP) is one criterion used for surgery in dislocated or displaced hips in children with cerebral palsy (CP). The MP at which a displaced hip can no longer return to normal is unclear. The aim of this paper was to identify the point of no return of the MP through a large population-based study. METHODS: All children registered on the Cerebral Palsy Integrated Pathway Scotland surveillance programme undergo regular pelvic radiographs. Any child who had a MP measuring over 35% since the programme's inception in 2013, in at least one hip and at one timepoint, was identified. The national radiography database was then interrogated to identify all pelvic radiographs for each of these children from birth through to the date of analysis. A minimum of a further two available radiographs following the initial measurement of MP ≥ 35% was required for inclusion. RESULTS: A total of 239 children (346 hips) were identified as suitable for analysis at a mean of 6.5 years (2.0 to 14.8) follow-up. In all, 1,485 radiographs taken both prior to and after a hip had a MP ≥ 35% were examined and the MP measured to identify any progression of displacement. Interrogation of the data identified that hips with a MP up to 46% returned to a MP below 40% without intervention, and all hips with a MP equal to or greater than 46% displaced further and the MP did not return to the normal range. Statistical analysis showed the result to be 98% specific with this degree of certainty that hips reaching a MP ≥ 46% would not spontaneously regress. CONCLUSION: These findings are clinically relevant in showing that it may be reasonable to continue to monitor hips with a MP not exceeding 46%. This threshold will also guide referral for further management of a displacing hip. Cite this article: Bone Joint J 2021;103-B(2):411-414.

Hip displacement and dislocation in a total population of children with cerebral palsy in Scotland.

AIMS: The purpose of this study was to compare the prevalence of hip displacement and dislocation in a total population of children with cerebral palsy (CP) in Scotland before and after the initiation of a hip surveillance programme. PATIENTS: A total of 2,155 children with CP are registered in the Cerebral Palsy Integrated Pathway Scotland (CPIPS) surveillance programme, which began in 2013. Physical examination and hip radiological data are collected according to nationally agreed protocols. METHODS: Age, Gross Motor Function Classification System (GMFCS) level, subtype of CP, migration percentage (MP), and details of hip surgery were analyzed for all children aged between two and 16 years taken from a time of census in March 2019 and compared to the same data from the initial registration of children in the CPIPS. Displacement of the hip was defined as a MP of between 40% and 99%, and dislocation as a MP of 100%. RESULTS: A total of 1,646 children were available for analysis at the time of the census and 1,171 at their first registration in CPIPS. The distribution of age, sex, and GMFCS levels were similar in the two groups. The prevalence of displacement and dislocation of the hip before surveillance began were 10% (117/1,171) and 2.5% (29/1,171) respectively, and at the time of the census were 4.5% (74/1,646) and 1.3% (21/1,646), respectively. Dislocation was only seen in GMFCS levels IV and V and displacement seen in 90.5% (67/74) of these levels and 9.5% (7/74) in levels I to III. In total, 138 children had undergone hip surgery during the study period. The hip redisplaced after the initial surgery in 15 children; seven of these had undergone a second procedure and at the time of the census the hips in all seven had a MP < 40. CONCLUSION: Hip surveillance appears to be effective and has reduced the prevalence of hip displacement by over half and dislocation almost by half in these children. Cite this article: Bone Joint J 2020;102-B(3):383-387.

Development of temporal and distance parameters of gait in normal children.

Temporal and distance parameters of 33 normal children were obtained from instrumented gait analysis prospectively over five consecutive years. The parameters were normalised to minimise the confounding effects of increasing height and leg length. Rank correlations were performed on normalised speed, normalised stride length, normalised cadence and normalised walk ratio across consecutive pairs of years to examine the ranking of these parameters for an individual child over time. Consistent trends of increasing rank correlation were observed in normalised stride length and normalised walk ratio suggesting that individual children were continuing to adjust these gait parameters towards their own characteristic position within the normal range. Consistent trends were not observed in the rank correlations for normalised speed and normalised cadence. These findings support the concept that individual children predominantly adjusted their cadence to effect changes in speed, while the development of stride length was dictated by other factors specific to the individual child. Rank correlation coefficients for walk ratio between consecutive years increased from the ages of 7-11 years of age and hence walk ratio appears be a feature of gait that matures beyond the age of 7 years. This accords with the proposal that it is an invariant parameter for an individual.

Bizarre parosteal osteochondromatous proliferation of the metatarsal: a pediatric case report and archival review.

UNLABELLED: Bizarre parosteal osteochondromatous proliferations (BPOP), also known as Nora's lesions, are rare tumors occurring most commonly in the hands and feet. They are benign and rarely exhibit radiological evidence of cortical invasion. We report a case of BPOP showing atypical magnetic resonance imaging features that are inconsistent with BPOP and having a novel chromosomal aberration. We also review the BPOP cases in our regional benign bone tumor database. LEVEL OF CLINICAL EVIDENCE: 4.

The effect of femoral orientation on the measurement of the head shaft angle: an ex-vivo study.

This laboratory study evaluates head shaft angle (HSA) reliability using ranges of simulated femoral orientation often seen in children with cerebral palsy. A dry femur was mounted in a jig that enabled the bone to be positioned in a range of internal and external rotation (-40° to + 40°) and flexion (0°-60°), alone or in combination. A metal wire was placed as a surrogate physis to give two HSA angles of 140° and 160°. Radiographs were taken of the femur in differing combinations of rotation, flexion and the two HSA angles. The HSA was measured by four independent observers on two separate occasions. Intraclass correlation coefficients (ICCs) were used to assess interobserver and intraobserver reliability. The HSA was accurately measured within ± 5° when the femur was positioned between 20° internal rotation and 40° external rotation. Flexion up to 60° did not affect the accuracy of the measurement. The interobserver reliability for the HSA was excellent with an ICC of 0.9970 [95% confidence interval (CI): 0.9995-0.9983] for the first measurement and 0.9988 for the second (95% CI: 0.9979-0.9993, all P < 0.01). The intraobserver reliability was also excellent with an ICC of not less than 0.990 for all four observers (95% CI: 0.9806-0.9986, all P < 0.01). There was excellent interobserver and intraobserver reliability when measuring the HSA in an experimental model provided femoral rotation lay within 20° internal and 40° external rotation and less than 60° of flexion.

Functional electrical stimulation to the dorsiflexors and quadriceps in children with cerebral palsy.

PURPOSE: To assess the effects of functional electrical stimulation (FES) of the ankle dorsiflexors and quadriceps in children with cerebral palsy. METHODS: Fourteen children (mean age 8 years) were randomly allocated to a treatment or control group. The treatment group received 2 weeks of neuromuscular electrical stimulation followed by 8 weeks of FES used at home and school. The control group continued with its usual physiotherapy program. Assessment took place at baseline and before and after the treatment period. Both control and treatment groups were fitted with FES for gait analysis at the second and final assessments. RESULTS: In both groups, FES of the ankle dorsiflexors resulted in a significant (p < 0.01) effect on gait kinematics. However, no long-term treatment effect of using FES for 8 weeks was found. CONCLUSIONS: FES for selected children with cerebral palsy, receiving adequate support, can be a practical treatment option to improve gait kinematics.

The mid-point of passive hip rotation range is an indicator of hip rotation in gait in cerebral palsy.

This study investigated the strength of any linear relationship between femoral anteversion and passive hip rotations, with rotation of the limb during gait. The data of 29 subjects (38 legs) with cerebral palsy (CP) were reviewed. Passive examination data were correlated with hip rotations during the whole gait cycle, and in stance only. Hip rotation in gait correlated significantly with passive external rotation (r=0.51-0.54), femoral anteversion (r=0.43-0.47), and passive internal rotation (r=0.36-0.41). The mid-point of passive hip rotation range correlated best with hip rotation in the stance phase of gait (r=0.57-0.58).

Guidewire damage during cannulated screw fixation for slipped capital femoral epiphysis.

Cannulated screw fixation of slipped capital femoral epiphysis is a standard procedure for the mild to moderately displaced slip. We report six cases in which the guidewire was damaged by a cannulated drill. In five the wire broke off within the femur. The broken wire was retrieved in two of the cases but not in the remaining three. The progress of all six patients was unaffected by this complication.

Repeatability of a new observational gait score for unilateral lower limb amputees.

The aim of this study was to assess the repeatability of an observational gait analysis score that was developed specifically for unilateral amputees. Ten videotaped sequences were analysed by six experienced observers on two separate occasions. Data were analysed using percentage agreement, the kappa statistic and the coefficient of repeatability. The score demonstrated good intraobserver repeatability with an average repeatability coefficient of 3 (range 1.5-4.6). Interobserver repeatability was poor with a repeatability coefficient of 5.9. This score could be used in practice to assess amputees and is most repeatable if used by the same observer to evaluate changes in patients over time.

Correlation of the Edinburgh Gait Score with the Gillette Gait Index, the Gillette Functional Assessment Questionnaire, and dimensionless speed.

This study examines the correlation of the Edinburgh Gait Score (EGS) with the Gillette Gait Index (GGI; formerly the Normalcy Index), the Gillette Functional Assessment Questionnaire, and speed, all of which are used as measures of gait quality or function. Scores were computed for 58 subjects, all with a diagnosis of cerebral palsy. The correlation of the EGS with all of the other scores was found to be significant, with r2 ranging from 0.26 to 0.79. The strongest correlation was found with the GGI, which may reflect common features in the derivation of both of these scores, although the EGS was derived from observational gait analysis and the GGI from principal component analysis of variables from computerized 3-dimensional gait data. We conclude that the EGS shows good concurrent validity with alternative gait assessment scores.

Passive and dynamic rotation of the lower limbs in children with diplegic cerebral palsy.

Rotation characteristics in gait and passive rotation of the lower limbs were evaluated retrospectively in 105 patients with diplegic cerebral palsy (65 males, 40 females; mean age 13y [SD 6y 9mo]; range 4y 4mo-40y 5mo). Of 105 patients, 22 (20.9%) required crutches, sticks, tripods, or a K-walker for their daily ambulation. Twelve (11.5%) patients used a wheelchair or buggy for community distances, e.g. shopping. Significant differences in rotational characteristics were found at the pelvis, hip, knee, and foot between left and right legs. Patients who were more affected on the right (group R, n=33) or the left side (group L, n=39) were re-evaluated. There was also a group of patients who were not asymmetrically affected (group S, n=33). In group L, maximum passive internal rotation was significantly greater on the left side, while no difference between the sides was found in group R. Peak internal rotation in gait was significantly higher on the right side in group R, but did not differ significantly between the sides in group L. Right hindfoot-thigh angle and transmalleolar axis were more external on the right, irrespective of which leg was more affected. These findings may have implications for the early non-operative management of limb posture in infants with diplegia and the surgical management of established lower extremity malrotation.

Gait analysis alters decision-making in cerebral palsy.

This study was designed to assess the impact of gait analysis on the treatment of patients with cerebral palsy. One hundred two ambulant patients with cerebral palsy were assessed clinically and with gait analysis. Separate treatment proposals for each patient were recorded after clinical examination and after gait analysis. The results of the two methods of assessment were compared. After clinical assessment, 71 of the 102 patients evaluated were recommended for a surgical procedure and 31 for nonoperative treatment. After gait analysis, the indications for treatment were confirmed in 91 cases (89%). Clinical assessment by the same orthopedic surgeon was in close agreement with gait analysis in identifying an indication for surgery. There was less agreement in the type or level of operation recommended. Gait analysis altered the decision in 106 of 267 operations (40%). There was good agreement for bone surgery, suggesting that clinical evaluation of torsional problems was fairly reliable. The poorer agreement seen for soft tissue operations probably reflects the difficulties in assessing tone-related problems in these patients clinically. This study confirms the value of gait analysis for decision-making in cerebral palsy.

Test-Retest repeatability of gluteus maximus strength testing using a fixed digital dynamometer in children with cerebral palsy.

OBJECTIVE: To investigate the test-retest repeatability of the measurement of the gluteus maximus strength using a fixed digital dynamometer. DESIGN: Test-retest design. The strength of the gluteus maximus was measured in prone position during 2 sessions an average of 6 days apart. SETTING: Gait analysis laboratory. PARTICIPANTS: Eleven children with spastic diplegic (n=10) and hemiplegic (n=1) cerebral palsy (CP), age 6 to 14 years, and 11 aged-matched children. All were able to walk independently, but 2 in the CP group used walking aids. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: On 2 occasions, gluteus maximus strength was measured 3 times in 2 positions of the hip joint. Repeatability of the measurements was assessed by intraclass correlation coefficients (ICCs), coefficients of variation, and the coefficient of repeatability. RESULTS: When normalized to body mass, children with CP had significantly less gluteus maximus strength compared with the controls. The ICCs for the control group ranged from .76 to .85 and from .75 to .83 for the involved leg in the CP group. CONCLUSIONS: The reliability of measurement of gluteus maximus strength was good for both control group and the involved leg of the CP group. The normalized values for gluteus maximus strength and measures of reproducibility can be used when measuring gluteus maximus strength in children with CP.

Edinburgh visual gait score for use in cerebral palsy.

Complex gait analysis systems are not generally available worldwide, and no simple system of assessing gait by observation has been validated specifically for use in patients with cerebral palsy. The authors have developed a visual gait analysis score for use in cerebral palsy. Videotaped sequences of patients were recorded before and after surgery as part of a three-dimensional gait study using a Vicon (Oxford, U.K.) gait analysis system. The score demonstrated good intraobserver and interobserver reliability. The numeric values of the score elements correlated well with the measurements obtained from instrumented gait analysis for the same patients, and the score was able to detect postoperative change.

Effects of surgical lengthening of the hamstrings without a concomitant distal rectus femoris transfer in ambulant patients with cerebral palsy.

Eighteen ambulant patients (32 legs) who had undergone fractional lengthening of the medial and lateral hamstrings without rectus femoris transfer underwent pre- and postoperative gait analysis. A significant increase in the amount of knee extension and a decrease in the amount of peak knee flexion in swing were observed. This decrease in knee flexion signified a change towards more normal speed-related values. Dorsiflexion at initial contact decreased significantly for patients who did not undergo a gastrocnemius lengthening (n = 24). Absolute cadence was significantly lower after surgery, but the change in dimensionless cadence was not significantly different. This difference in the outcome between dimensionless and absolute stride parameters can be attributed to the increase in body height after surgery. The clinical significance of these findings is that it is important to recognize that postoperative effects of surgery on gait in children may, in part, be explained by changes in height and not surgery alone.