A proactive hip surveillance programme for Cerebral Palsy Sufferers set up in Cork delivered positive results. It should be emulated and rolled out across the country according to the team’s spokesperson, Gillian O’Dwyer, Physiotherapy Manager, Enable Ireland.
Every child should be referred for hip surveillance at the time that Cerebral Palsy is identified according to the ground-breaking study and subsequent protocol – the Australian Consensus Statement – which emerged from Australia in 2008. Sadly this doesn’t happen in Ireland, and unlike other countries such as the UK, Sweden and Australia, we do not have a national screening programme to prevent hip dislocations in Cerebral Palsy patients. Such a programme would prevent a lot of unnecessary pain for CP patients, and potentially prevent spinal scoliosis in some.
Hip Displacement is common in children with cerebral palsy (CP) with incidence varying from 35% to 50% (Soo et al, 2006; Morton et al, 2006). The risk of Hip Displacement/Dislocation is directly related to the child’s gross motor function. Children with more severe motor problems assessed as level 3, 4 or 5 on Gross Motor Function Classification System (GMCSs) are considerably more likely to develop hip displacement than their peers with milder involvement (Soo et al, 2001).
The long term consequences of hip displacement include reduced hip flexion leading to pelvic asymmetry/obliquity which increases risk of spinal scoliosis (Letts et al, 1984) and hip pain (Cooperman et al, 1987).
While one study (Scrutton et al 2001) recommends radiological surveillance of CP children from 30 months, another (Dobson et al 2006) noted that hips may begin to displace as early as 18months, and advocated commencing radiological surveillance before this age for all children with bilateral cerebral palsy.
The UK, Scandinavia and Australia all have established hip assessment clinics and several major studies have described their establishment and success. Other studies have demonstrated how different professionals and services can work together as a team. We have worked in this manner in Cork: our Paediatricians, Physiotherapists and Paediatric Orthopaedic Surgeons joining forces and becoming more of the sum of their parts under the protocol. Such a coordinated approach has been proven to assist in the prevention of hip dislocation, and also other secondary impairments, such as upper and lower limb muscle and joint contractures, pelvic obliquity and scoliosis (Lund, 2007).
Thus, the preventative impact of Hip Surveillance Programmes for CP patients has been known for some time. A large study in 2002 (Dobson et al) demonstrated the impact of hip surveillance in children (HSC) on surgical intervention. In the 12 months pre-HSC, 36% of surgery was preventative, 26% reconstructive and 8% salvage for hip subluxation/dislocation in children with bilateral CP. Three years after adopting the HSC protocol, 61% of surgery was preventative, 25% reconstructive and 0% salvage over a 12 month period for the bilateral CP population
A team from Enable Ireland Children’s Services attended the First international Conference on the Management of Hip in CP in March 2010, in Liverpool. This galvanised an initiative to pull together an interdisciplinary team including Physiotherapists, Occupational Therapists, Paediatricians and Paediatric Orthopaedic Surgeons. Since 2010, this group provides an early prevention and intervention surveillance for secondary musculoskeletal complications that occur secondary to neurological conditions such as Cerebral Palsy. There are at present 520 clients in the EI service.
Following admission to Enable Ireland Cork all clients with Cerebral Palsy receive a Neuro-Orthopaedic assessment to provide a baseline assessment on referral. This is a comprehensive population based screening and prevention programme, which is essential to the success of this programme and ensures timely referral for Early Intervention Neurological Treatment and Handling, Neurological Casting, Orthotics, Specialised Seating, Night Positioning, Dynamic Standing as appropriate, spasticity Management Interventions with Paediatricians, BTX-A/Baclofen etc.
The programme aims to detect “hips at risk” in children with CP from an early age allowing for preventative therapeutic interventions to minimise and if possible avoid progressive hip subluxation and subsequent dislocation.
Results of data from the Enable Ireland Cork Hip Surveillance Protocol since 2010 were analysed by Mr Ryan Johnson, final year medical student at UCC under the supervision of Dr Louise Gibson. The analysis showed promising trends: prevalence rates for both hip subluxation and dislocation fell and as a result of the surveillance there is reason to believe that children are receiving hip x-rays and patient-specific orthopaedic referrals at the appropriate time (see attached).
It is vital to all Irish CP children that this hip surveillance programme be rolled out nationally. This is a cost-neutral initiative since it requires no further funding to co-ordinate nationally. It simply needs the relevant clinicians to adopt and work together according to the protocol.
Enable Ireland and Straight Ahead, the charity which provides free surgery for children with complex Orthopaedic Conditions at Our Lady’s Children’s Hospital, is hosting a conference on Paediatric Spasticity and Orthopaedic Management in the Rochestown Park Hotel in Cork on April 26th. Speakers include international experts on Paediatric Orthopaedics and include Mr Freeman Miller, Martin Gough, Jos de Cat and Gill Holmes as well as Irish Paediatric Orthopaedic Surgeons Ms Sinead Boran, Mr Pat Kiely and Mr Colm Taylor.
The conference aims to identify best practice in this area and promote a national screening protocol which will ultimately improve the quality of life of children and young people with CP in Ireland.