Kate Willoughby

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.

Progressive resistance training and mobility‐related function in young people with cerebral palsy: a randomized controlled trial

The aim of this study was to investigate whether individualized resistance training improves the physical mobility of young people with cerebral palsy (CP).

The impact of botulinum toxin A and abduction bracing on long-term hip development in children with cerebral palsy.

Aim  To study the long‐term impact of 3 years of botulinum toxin A (BoNT‐A) injections and abduction bracing on hip development in children with bilateral spastic cerebral palsy (CP). We wanted to know if early treatment improved hip development and reduced the need for surgery.

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

To ensure hip surveillance guidelines reflect current evidence of factors influencing hip displacement in children with cerebral palsy (CP).

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

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.

The radiological assessment of pelvic obliquity in cerebral palsy and the impact on hip development

Pelvic obliquity is a common finding in adolescents with cerebral palsy, however, there is little agreement on its measurement or relationship with hip development at different gross motor function classification system (GMFCS) levels. The purpose of this investigation was to study these issues in a large, population-based cohort of adolescents with cerebral palsy at transition into adult services. The cohort were a subset of a three year birth cohort (n = 98, 65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their last radiological review) with the common features of a migration percentage greater than 30% and a history of adductor release surgery. Different radiological methods of measuring pelvic obliquity were investigated in 40 patients and the angle between the acetabular tear drops (ITDL) and the horizontal reference frame of the radiograph was found to be reliable, with good face validity. This was selected for further study in all 98 patients. The median pelvic obliquity was 4° (interquartile range 2° to 8°). There was a strong correlation between hip morphology and the presence of pelvic obliquity (effect of ITDL on Sharpes angle in the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p < 0.001). This was particularly true in non-ambulant adolescents (GMFCS IV and V) with severe pelvic obliquity, but was also easily detectable and clinically relevant in ambulant adolescents with mild pelvic obliquity. The identification of pelvic obliquity and its management deserves closer scrutiny in children and adolescents with cerebral palsy.

The impact of complementary and alternative medicine on hip development in children with cerebral palsy

This study aimed to evaluate the effect of complementary and alternative medicine (CAM) approaches on long‐term surgical requirements, and clinical and radiographic outcomes for children with cerebral palsy and hip displacement.

2D versus 3D imaging of hip displacement in children with cerebral palsy

In population-based studies, hip displacement was found to affect approximately one-third of children with cerebral palsy and was directly related to functional limitations as classified according to the Gross Motor Function Classification System (GMFCS), but not the type of movement disorder. For many years, hip development in children has routinely been assessed and monitored using plain radiography, i.e. two-dimensional (2D) imaging. In children with cerebral palsy, an anteroposterior X-ray of the pelvis has been used as a basis for hip surveillance and to design a classification of hip morphology at skeletal maturity as an outcome measure. Two-dimensional imaging of the hip can yield reliable images on which decisions can be made for referral and for intervention such as adductor releases, and to monitor the outcome of such surgery. It is widely available and with attention to positioning of the child and measurement technique, is capable of producing reliable results. In addition the dose of radiation is small, typically ranging from 0.1 to 0.6mSv per image. Gose et al. have conducted a careful and detailed study of three-dimensional (3D) imaging of the hip using a multidetector computed tomography (CT) protocol with ‘ageand weight-specific pediatric protocols’ to limit the dose of radiation. The authors report a substantial body of new information, which can be helpful in understanding the pathology of hip displacement in children with cerebral palsy, including precise assessment of acetabular morphology, and proximal femoral geometry. This is the largest published study of 3D imaging of the hip in children with cerebral palsy to date and the information gained may be important on many levels. This study also demonstrates the relationship between functional status according to GMFCS level and hip morphology. It also validates the classification of hip morphology reported by Robin et al., based on 2D imaging. However, the question remains as to when 2D imaging of the hip is appropriate and when 3D imaging should be utilized? The principal disadvantages of 3D imaging are the more limited accessibility of CT in some hospitals, the need for sedation to gain images of good quality for children unable to keep still, and the increased dose of radiation received by the child. Typical radiation doses for CT scans of the hips are in the range of 3 to 4mSv, which is greater than the world average annual background of radiation of about 2.4mSv per annum. The radiation dose for a CT scan of the hips is between 10 and 20 times the radiation dose for a single anteroposterior radiograph of the pelvis. The difference will vary with the CT imaging parameters, the volume of tissue scanned, and the radiographic technique for the pelvic X-ray. So the question therefore is when is the additional patient time, expense, and radiation dose justifiable in terms of the much more detailed information available from the procedure? Two-dimensional, plain radiography seems to be adequate for hip surveillance in the younger child, so long as correct positioning, technique, and measurement are undertaken. Two-dimensional imaging is also adequate for assessing the outcome of soft-tissue surgery by adductor releases and as a simple measure of hip morphology at skeletal maturity. However, in older children, with severe hip displacement, the study by Gose et al. demonstrates a range of deformities affecting both the acetabulum and the proximal femur which may give useful information to orthopaedic surgeons treating an individual patient. This information adds to those from earlier work by Brunner et al. which reported the magnitude and direction of acetabular deformity in older children with cerebral palsy and severe hip displacement. These and other authors have commented on the benefits of this additional information in planning reconstructive surgery. In addition, the same authors have noted the inaccuracy of the migration percentage, measured from 2D radiographs of the hip in predicting femoral head displacement in six children with cerebral palsy who had anterior displacement of the hip. However, the direction of hip displacement in cerebral palsy is posterolateral or posterior in the majority of children. Pure anterior displacement is rare and can be recognized clinically by progressive limitation of hip flexion. In our opinion, 2D radiography of the hips would seem to be the criterion standard for initial diagnosis of hip displacement and for hip surveillance. Three-dimensional imaging with CT may be indicated if there is clinical suspicion of anterior hip displacement, obscure hip pain, and when there is established deformity in the acetabulum or proximal femur, prior to bony reconstruction. By this means important information for the surgeon, such as the direction of the dislocation and the morphology of the acetabulum, can be obtained. In the interests of child safety and parental education, it is increasingly important for clinicians to be aware of the risk versus benefit of diagnostic procedures and in this context, a greater radiation dose associated with CT compared to 2D plain radiology. The alternative modality for 3D imaging of the hip is magnetic resonance imaging. However, the scanning times are much longer than for CT and the benefit of no ionizing radiation may be outweighed by the need for general anaesthesia, in the majority of children with cerebral palsy.

Integrated Management in Cerebral Palsy: Musculoskeletal Surgery and Rehabilitation in Ambulatory Patients

In this chapter, current treatment concepts for ambulatory children with cerebral palsy (CP) will be introduced and discussed. The Gross Motor Function Classification System (GMFCS) was the first of the family of classification systems, which have given clinicians a common language with which to communicate about cerebral palsy.

Screening and referral for children with physical disabilities

The clinical care of children with physical disabilities is a major priority for paediatricians and paediatric orthopaedic surgeons. Cerebral palsy (CP) is the prototypical condition and remains the most common cause of physical disability in developed countries. The incidence is approximately 2 per 1000 live births, translating to between 600 and 700 new children per annum in Australia, with approximately 34 000 children and adults currently living with CP. This figure is predicted to rise inexorably over the next 20 years. The care of children with physical disabilities, including those with CP, is usually coordinated by paediatricians, general practitioners and allied health teams including physiotherapists, with input from paediatric orthopaedic surgeons when appropriate. The emphasis in care for children with CP has moved from ‘reactive’ to ‘proactive’. In the past, children are often referred when symptomatic, for example when a hip dislocation had occurred and became painful. The emphasis now is on coordinated, multidisciplinary care in which musculoskeletal manifestations of disability are identified by screening programmes. Systematic screening, especially when population‐based and linked to a register, avoids children getting ‘lost in the system’. Early and more effective interventions may be offered for the prevention of contractures, dislocation of the hip and spinal deformities. In this review, we will focus on the assessment of gait in children with physical disabilities, and monitoring for hip and spine deformity.