Hip Subluxation and Dislocation in CP

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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,

Chailey Heritage Clinical Services, North Chailey,

East Sussex BN8 4JN, UK (E-mail: Terry.

Pountney @southdowns.nhs.uk).

(Submitted April 2008; accepted October 2008)


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Documents

Hip Subluxation and Dislocation in CP