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Common Musculoskeletal Problems With Cerebral Palsy

Cerebral Palsy Center at Nemours/Alfred I. duPont Hospital for Children

1600 Rockland Road, Wilmington, DE, USA 19803 | Get Map & Directions »


The Cerebral Palsy Center at the Nemours/Alfred I. duPont Hospital for Children provides expert care for children with cerebral palsy (CP). Our multidisciplinary team of experts from orthopedics, neurology and other specialties has extensive experience with a wide range of problems commonly found in children with CP. This includes hip dislocations, scoliosis (a curving of the spine), spasticity (severe muscle stiffness) and gait (walking) problems.

Hip Dislocation

 
What Is Hip Dislocation and What Causes It?

When a hip is dislocated, the ball at the top of the femur (thigh bone) doesn’t fit firmly into the socket, which is part of the pelvis. The ball can be loose in the socket, making it easy to dislocate.

A hip dislocation (also called “dysplasia”) can occur:
  • developmentally in babies
  • over time due to growth or stresses from muscles and other joints
    from an injury to the hip joint

In children with cerebral palsy (CP), poor muscle control, severe weakness or severe spasticity (extreme muscle stiffness) can cause hip dislocations.

 
Which Children Develop Hip Dislocations?

Hip dislocations occur in children with more severe forms of cerebral palsy. Those who aren’t able to walk without the assistance of a walker or can’t walk at all are at high risk. Children who walk without needing any assistive device are at low risk.

 
At What Age Do Hip Dislocations Develop?

Most hip dislocations occur in children between the ages of 2 and 8 years old. The most common age for hips to begin dislocating is 3 to 5 years old. Dislocation can occur, however, at any time until a child is completely finished growing.

 
Can Hip Dislocations Be Prevented?

Careful monitoring of your child’s hips can help identify the early stages of hip dislocation, so that we can start treatment early and try to lessen the amount of dislocation and its impact upon your child. We recommend examining and doing an X-ray of your child’s hips every year from ages 2 to 8.

Please note that there’s no scientific evidence that braces or stretching prevent hip dislocation. Also, scientific studies of the effect of Botox (a protein that helps to relax the muscles) have found that it doesn’t prevent hip dislocation or subluxation (incomplete or partial dislocation of a joint).

 
How Do We Treat Hip Dislocations?

The key to getting the best treatment for your child is early identification. X-rays are recommended every year from age 2 to 8, and every two years after age 8 until a child with CP has finished growing. This will allow us to measure how much of the head of the femur is outside the socket. This is called the “migration percent” (or “MP”). If the hip is normal, the MP is less than 25. Treatment may involve muscle lengthening at the hip to improve motion for those children who are spastic (severe muscle stiffness) or have limited motion. Although some surgeons prefer to instead perform a bone shortening procedure (called an “osteotomy”), the recovery from the muscle surgery is much quicker. In our care, 60 percent of children with an MP 30 don’t need further treatment and end up with hips that are normal and don’t dislocate.

For children ages 8 and older, and with an MP greater than 40 percent, we recommend a full hip reconstruction before the hip dislocates because the outcomes are better than waiting until there’s full dislocation. In this way, these older children typically end up with a good, functional hip and no pain. Although this is a major surgery, it requires no casting, allowing immediate postoperative motion and standing in most children.

For children who have a severe dislocation with arthritis and pain, the treatment options are much more limited. Common treatments include total hip replacement, and two types of treatment that we do not usually recommend — hip joint resection (the removal of all or part of the hip joint, which leaves the leg floppy and unable to bear weight) and hip fusion (joining the bones of the femur and pelvis together, strengthening the joint but eliminating range of motion). With proper early identification and treatment, these two options can usually be avoided.

Scoliosis

 
What Is Scoliosis and What Causes It?

Scoliosis is a sideways curvature of the spine that has many causes. In children with cerebral palsy (CP), the causes are usually poor control of the muscles and fast growth of the spine. In the general population, scoliosis most commonly occurs in teenage girls, for reasons doctors still don’t know. It also occurs in children with muscular dystrophy due to weak muscles, and in children with osteogenesis imperfecta due to weak bones.

 
Which Children Develop Scoliosis?

Scoliosis most often develops in children with more severe forms of cerebral palsy — mainly those who have no ability to walk by themselves, even with a walker.

 
At What Age Does Scoliosis Develop?

Scoliosis most often begins to develop in late childhood — between 8 and 10 years old — and then progresses rapidly during the adolescent growth period. We can diagnose scoliosis by having a child bend forward when sitting. If there’s a difference between the right and left sides (this is called “asymmetry”) of the chest or lumbar region, we’ll recommend a test called a sitting full-spine X-ray. The degree of curvature when children typically start having more problems sitting is around 50 degrees. If a child is young, we’ll usually wait until the scoliosis is around 70–90 degrees before we recommend surgery.

 
Can Scoliosis Be Prevented?

Currently, we don’t know any way to prevent scoliosis. We can help make children more comfortable, though, with well-supported seating positions and stretching.

 
How Do We Treat Scoliosis?

Although scoliosis in teenage girls is frequently treated with a body brace, the evidence shows that bracing has no effect on curve progression for children with cerebral palsy (CP). A full-time or night-time body brace can also be uncomfortable and restrict breathing in kids with CP. For some children, we may recommend a soft body brace to provide sitting support as the spine curves.

We do not typically recommend some treatments for scoliosis that others may attempt, such as injections of Botox (a protein that helps to relax the muscles), massage, chiropractic manipulation and therapy. None of these have been proven to have an identifiable impact on scoliosis, so we don’t usually suggest their use for scoliosis.

The primary treatment for scoliosis in the majority of children with CP is spinal fusion, in which the whole spine (from the top of the neck to the pelvis) is stabilized with rods and wires or screws. These are major operations, but children are usually able to get around using wheel chairs in three to four days, and can often return to their normal level of activity within four weeks.

Occasionally, a child with cerebral palsy who is able to walk develops scoliosis in a smaller region of the back. In cases like this, we recommend a fusion procedure for just the portion of the spine affected.

Spasticity

 
What Is Spasticity and What Causes It?

Spasticity is severe stiffness in a child’s muscles. It can be seen when a child attempts to move a limb, or when someone else is trying to move the child’s limb. It may cause jerking motions (sometimes called “clonus”), especially of the ankle and sometimes even the whole leg. The cause of spasticity is in the specific area of the child’s brain that’s damaged. This damage prevents normal muscle control and allows uncontrolled signals to be sent to the muscles.

Spasticity may feel like a muscle cramp, but it’s usually not painful. Spasticity makes movement difficult and also causes the muscles to not grow as fast as the bones. This, in turn, causes muscle shortness, especially during rapid growth periods. Spasticity can help, though, by providing stability and strength for a child to stand and sit.

 
Which Children Develop Spasticity?

Children with any level of severity of cerebral palsy (CP) may develop spasticity, especially in the limbs most involved with their CP. It’s usually worse in children with more limited ability to move, but it can be a major problem for children with even mild forms of CP who walk without any assistance.

 
At What Age Does Spasticity Develop?

We usually see the first signs of spasticity developing in children between 1 and 2 years of age, then it slowly gets worse as they grow. In many children, spasticity seems to level off in middle childhood (between 6 and 8 years of age) and may get better. In some children, though, it can increase. Every child is different, though, so how spasticity affects a child will vary.

 
Can Spasticity Be Prevented?

Doctors don’t currently know of any way to prevent spasticity. For many children with cerebral palsy, spasticity actually helps them to stand and sit

 
How Do We Treat Spasticity?

For many children, spasticity does cause problems, such as an inability to get their feet flat on the ground or their knees straight for standing. For your child, the ideal treatment depends on your child’s:

  • age
  • functional level
  • any problems the spasticity is causing
  • the short- and long-term goals you and your child may have

Our experience with all the available treatment options helps us make expert, specific recommendations for you and your child.

Treatment options include:
  • Activity and stretching exercises for the spastic limb or limbs for children with limited movement ability. This provides temporary relaxation, but not long-term relief.
  • Muscle strength training for older children and teenagers. This is very helpful and reduces the spasticity and its impact upon movement.
  • Oral medications — Diazepam (Valium) is the most potent, which is excellent after surgery or injury to decrease spasticity (which usually increases with pain or illness). Baclofen is another oral medication that’s helpful over time for some children. However, most children with cerebral palsy find it loses effectiveness and the spasticity comes back when they stop taking it.
  • Botox (a protein that helps to relax the muscles) injections, which is a medication that’s injected directly into the spastic muscle. It causes a partial weakening of the muscle that lasts for about four months. During this time, children often make gains in function and even progress developmentally. These gains are maintained even when the spasticity returns. Repeat injections can be performed, but each subsequent injection is less effective, as the body can develop immunity. Usually, three or four injections are all that’s needed to provide functional gain. There’s no evidence that injections given in advance to prevent spasticity provide any benefit. In fact, published data shows that repeated injections cause increasing scarring in the muscle, which means the muscle doesn’t fully recover after each injection.
  • Baclofen pump, which allows for placement of the medicine baclofen directly in the fluid that surrounds the spinal nerves. This requires surgical implantation of the pump in the abdomen, with a catheter directed into the spinal canal. Compared to oral delivery, a much smaller amount of the medicine is needed. The risks and complications need to be considered but, overall, this is the most effective treatment of severe spasticity. One major advantage is the ability to adjust the dose of the drug to remove as much spasticity as is helpful for a child. If more spasticity is better for an individual, less of the medication is given.
  • Dorsal rhizotomy, a procedure in which spasticity is reduced by cutting the nerves causing it. There’s immediate reduction in spasticity. The procedure does bring about severe weakness in the affected muscles, but many children overcome this with strengthening in physical therapy. If so, walking ability is also improved. The procedure is best for children who can walk without using a walker or crutches. The main complications include longer-term weakness, decreased sensation in the legs, occasional back pain and a potential need for repeat spine surgery.
  • Muscle lengthening — because spasticity prevents the normal growth of the muscles, so they end up shorter that the bones. The muscles are then quicker to be stretched to their limits, which initiates the spasticity. In a muscle lengthening procedure, the muscles can be lengthened surgically by lengthening the tendon. This allows for more joint movement and reduces the amount the muscles need to stretch, which reduces the spasticity. One benefit is that this is a minor operation. A complication is that the muscle will again get short as a child grows, so the procedure often has to be repeated several times in the child’s life.
  • Alcohol or phenol injections, which are delivered directly into the muscle. Although these injections decrease spasticity, they cause permanent death to the tissue with scarring, severe weakness and contracture (a permanent shortening of a muscle). They should not be used.

Gait Problems

 
What Are Gait Problems and What Causes Them?

Gait is the pattern of how a person walks. Children with cerebral palsy (CP) can have many different problems walking. Most children have some delay in starting to walk and when they do start walking, they often walk up their toes (this is called “toe walking”) and need to use a walker for assistance. Many children also develop turned-in or turned-out knees and feet, flat feet and increased knee flexion (bending of the leg at the knee joint).

 
Which Children Develop Gait Problems?

Almost all children with cerebral palsy (CP) who have the ability to walk develop some problems with their gait. Some of this is due to spasticity, which is addressed with treatment options for spasticity. Many of the problems develop as children grow and their gait matures. For example, a child may start walking at 2 to 3 years old and have stiff knees and walk only on the toes. Then, by age 12, the feet collapse into severe flat feet and the knees are very flexed. We see a wide variety of gait patterns in children with CP.

 
At What Age Do Gait Problems Develop?

From the age when a child starts to walk, we need to evaluate issues and problems relating to the legs. Because there continues to be significant changes in muscle lengths and bone shapes during a child’s growth, we’ll continue to assess your child until adolescent growth is complete.

 
Can Gait Problems Be Prevented?

Some problems can’t be prevented. For example, growth causes some muscles to not keep up with the bones, which means that the muscles become shorter. In some children, the bones develop torsion (or twisting).

 
How Do We Treat Gait Problems?

Overall, our treatment of gait problems focuses on correcting mechanical problems and encouraging children to be as active as they can be. We use orthotics (devices or inserts to assist or modify your child’s movements) only when they provide a direct benefit or make a child walk better. Most children are able to be out of orthotics by 8 to 10 years old to allow their muscles to grow stronger. Weakness is a major problem for children with cerebral palsy, so much of our current focus is on trying to improve strength and limiting things that cause weakness. Most children’s gaits continue to improve between 8 and 10 years old.

Common treatment options for gait problems include:
  • 2–4 years old — During the early years of walking, our focus is on appropriate orthotics, physical therapy and possible use of Botox for spasticity control.
  • 4–7 years old — This is the time children are preparing to attend school, if this is appropriate for an individual child. During this period, we try to have children walking in the most functional way possible. This is also the time when most children would be considered for surgeries such as muscle lengthening and spasticity surgery (such as baclofen pump implantation). Therapy and appropriate braces continue to be important.
  • 8–12 years old — This is the age when most children reach a plateau in their ability to walk — meaning that their ability to walk stays the same, without a decrease or increase. During this time, we use appropriate surgical procedures to treat problems such as severe in-toeing or out-toeing (when the feet turn inward or outward), turning in of the knees and knocking knees. (Most of the surgery involves multiple areas and is called “single event multilevel surgery,” or “SEMLS,” for short.) To figure out the specific surgery children might need, we’ll perform a full computerized gait analysis. This allows careful measurement and documentation of all the problems that require correction. After bone and muscle surgeries, the initial recovery may require three months, and children will usually get physical therapy and practice walking. Improvement in walking often continues for two years.
  • 13 years old, until growth ends — During this time of adolescent growth with fast weight gain, collapse of the feet into severe flat feet can occur. This is often accompanied by an increase in knee bending (“flexion”) during walking. This is called “crouch gait,” and can cause periods of severe knee pain. As children grow and have more problems walking (especially if they’re having pain), we may recommend surgical corrections, especially to help prevent a child’s loss of the ability to walk. It’s very hard to get children back to walking once they’re in a wheel chair full-time. We plan surgery with the benefit of a full gait analysis to define all of the problems and the issues that need to be addressed. Surgery may require correction of flat feet, bone surgery to align the legs correctly, and muscle lengthening. The rehabilitation period during this age range is often longer than for younger children because the child is bigger and a little slower to move.
mother and daughter at the Cerebral Palsy Center

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