The natural history of hip development in cerebral palsy

Department of Orthopaedic Surgery, Oslo University Hospital, Rikshospitalet and University of Oslo, Oslo, Norway.
Developmental Medicine & Child Neurology (Impact Factor: 3.51). 08/2012; 54(10):951-7. DOI: 10.1111/j.1469-8749.2012.04385.x
Source: PubMed


The purpose of this study was to evaluate a population-based radiographic hip surveillance programme for children with cerebral palsy (CP) and to assess the natural history of hip displacement.

The study comprised 335 children (188 males, 147 females), born during 2002 to 2006 in the 10 south-eastern counties in Norway. Their mean age at the first radiograph was 3 years (range 6mo-7y 11mo) and the mean age at the most recent follow-up was 5 years 5 months. Distribution according to CP type was spastic hemiplegia in 38%, diplegia in 27%, quadriplegia in 21%, dyskinesia in 10%, and ataxia in 3%; Gross Motor Function Classification System (GMFCS) levels I to V were, 44%, 14%, 8%, 11%, and 23% respectively. Migration percentage (MP), acetabular index, and pelvic obliquity were measured on the radiographs.

Hip displacement (MP>33%) occurred in 26% of all children (subluxation in 22% and dislocation in 4%) and in 63% of those in GMFCS levels IV or V. Dislocation occurred in 14 children at a mean age of 4 years 5 months (range 1y 10mo-9y 7mo). The mean migration percentage was 20.4% at the initial radiographs and 34.0% at the last follow-up. Mean progression in migration percentage increased markedly with decreasing functional level, from 0.2% per year at GMFCS level I to 9.5% at level V.

There is a pronounced trend towards hip displacement in nonambulant children. Close surveillance from age 1 to 2 years is needed to find the appropriate time for preventive surgery. Since 12% of the nonambulant children developed dislocation, our routines for hip surveillance need improvement.

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    • "Hip pain results from the stimulation of free endings of slow-conducting nerve fibres with nociceptive input. This effect can be amplified by biochemical agents, such as bradykinin or histamine, which may activate the endings of nerve fibres, triggering pain, while other agents, such as substance P or prostaglandins, mainly enhance the sensitivity to applied stimuli [14,15]. Moreover, a persistent noxious, mechanical, or thermal stimulation input can be involved in developing or increasing central sensitization and release processes, leading to or supporting chronic pain. "
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    ABSTRACT: Backgrounds: Non-traumatic hip dislocation in children is most often observed in the course of developmental dysplasia of the hip (DDH) and infantile cerebral palsy. The risk of pain sensations from dislocated hip joint differentiates the discussed groups of patients. Will every painless hip joint in children with cerebral palsy painful in the future? Material included 34 samples of joint capsule and 34 femoral head ligaments, collected during open hip joint reduction from 19 children with CP, GMFCS level V and from 15 children with DDH and unilateral hip dislocation. All the children were surgically treated.The density of nociceptive fibres was compared between the children with CP and DDH, using S-100 and substance P monoclonal antibodies. More frequent positive immunohistochemical reaction to S-100 protein concerned structures of the femoral head ligaments in children with CP and cartilage losses on the femoral head, when compared to the same structures in children with DDH (p = 0.010). More frequent were found positive immunohistochemical reactions for S-100 protein in the joint capsules of children with cartilage losses (p = 0.031) and pain ailments vs. the children with DDH (p = 0.027). More frequent positive reaction to substance P concerned in femoral head ligaments in CP children and cartilage lesions (p = 0.002) or with pain ailments (p = 0.001) vs. the DDH children. Surgical treatment of hip joint dislocation should be regarded as a prophylactics of pain sensations, induced by tissue sensitisation, inflammatory process development or articular cartilage defects.
    BMC Musculoskeletal Disorders 03/2014; 15(1):96. DOI:10.1186/1471-2474-15-96 · 1.72 Impact Factor
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    • "Although the final outcome of early intervention at skeletal maturity is not clear [17,18], early risk assessment might enable earlier referral for those children who may benefit from preventative intervention [19]. As clinical assessment of hip range of motion is a poor predictor of risk, several radiological and clinical measures are used to diagnose and monitor hip subluxation [13,16,17,19]. While functional disability, pain [20] and impaired ambulatory weight-bearing [12,16,18,19] are associated with risk of hip displacement and need for surgical intervention, the evidence regarding radiological characteristics is less clear [21,22]. "
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    ABSTRACT: Background Cerebral palsy (CP) results from a static brain lesion during pregnancy or early life and remains the most common cause of physical disability in children (1 in 500). While the brain lesion is static, the physical manifestations and medical issues may progress resulting in altered motor patterns. To date, there are no prospective longitudinal studies of CP that follow a birth cohort to track early gross and fine motor development and use Magnetic Resonance Imaging (MRI) to determine the anatomical pattern and likely timing of the brain lesion. Existing studies do not consider treatment costs and outcomes. This study aims to determine the pathway(s) to motor outcome from diagnosis at 18 months corrected age (c.a.) to outcome at 5 years in relation to the nature of the brain lesion (using structural MRI). Methods This prospective cohort study aims to recruit a total of 240 children diagnosed with CP born in Victoria (birth years 2004 and 2005) and Queensland (birth years 2006–2009). Children can enter the study at any time between 18 months to 5 years of age and will be assessed at 18, 24, 30, 36, 48 and 60 months c.a. Outcomes include gross motor function (GMFM-66 & GMFM-88), Gross Motor Function Classification System (GMFCS); musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function (Manual Ability Classification System), communication difficulties using Communication and Symbolic Behaviour Scales-Developmental Profile (CSBS-DP), participation using the Paediatric Evaluation of Disability Inventory (PEDI), parent reported quality of life and classification of medical and allied health resource use and determination of the aetiology of CP using clinical evaluation combined with MRI. The relationship between the pathways to motor outcome and the nature of the brain lesion will be analysed using multiple methods including non-linear modelling, multilevel mixed-effects models and generalised estimating equations. Discussion This protocol describes a large population-based study of early motor development and brain structure in a representative sample of preschool aged children with CP, using direct clinical assessment. The results of this study will be published in peer reviewed journals and presented at relevant international conferences. Trial registration Australia and New Zealand Clinical Trials Register (ACTRN1261200169820)
    BMC Neurology 06/2013; 13(1):57. DOI:10.1186/1471-2377-13-57 · 2.04 Impact Factor
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    ABSTRACT: This commentary is on the original article by Murphy et al. on pages 945‐950 of this issue.
    Developmental Medicine & Child Neurology 07/2012; 54(10):877-8. DOI:10.1111/j.1469-8749.2012.04363.x · 3.51 Impact Factor
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