Equipment Options and Positioning Recommendations …/media/files/Childrens/medical-professionals/... · Equipment Options and Positioning Recommendations to ... Glickman, L., (2013),

Equipment Options and

Positioning Recommendations to

Encourage “Hip Health”

Michele E. Audet, MMSc,PT,ATP/SMS

Children’s Healthcare of Atlanta

Hip – Cerebral Palsy

• Children with cerebral palsy are rarely born with hip dysplasia.

• Developmental hip dysplasia is a very commoncomplication of children with cerebral palsy and canlead to significant disability and pain.


Hip Development

• Growth of a child’s hip occurs in a sequential process from embryo up to adolescence.

• Cartilage in the acetabulum serves to deepen the hip socket resulting in more complete coverage of the femoral head = More stable hip.


Hip Development

• Development of the acetabulum is dependent uponarticulation of the femoral head in the acetabulum and is promoted through Weight Bearing.

• Zeng,S., et.al., (2013), Coverage of femoral head at weight-bearing interface of the hip joint in children: an MRI analysis. Open J. of Medical Imaging, 3, 60-64.


Normal Hip With Cartilage

• (Image removed due to copyright policy)


Definition Hip Displacement

• Gradual, lateral displacement of the femoral headfrom under the acetabulum.

• Hip displacement often used interchangeably withhip subluxation.

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Migration Percentage

http://www.biomedcentral.com/content/figures/1471-2474-8-101-1-l.jpg


Hip Dislocation

• Femoral head is completely laterally displaced fromunder the acetabulum.

• MP = 100%

• Other definitions include MP of > 80%.

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Hip – Cerebral Palsy

• GMFCS can be used to determine which children are at the highest risk for displacement.


Hip Displacement - CP

• Soo et. al. -374 children with CP in Australia bornbetween 1990 and 1992.

• Mean follow-up 11 years, 8 months.

• Incidence of hip displacement entire group was 35%.

• Incidence GMFCS Level I =0%. Level V = 90%

Soo, B., Howard, J., Boyd, R., et.al. (2006), Hip stability in cerebral palsy. J. Bone Joint Surg AM, Jan (88)1, 121-129.


Hip Displacement - CP

• Hagglund et.al. – 212 children with cerebral palsy in Sweden.

• Followed using X-rays until age 9-16 years old.

• 27% developed hip displacement > 33% and of these 18% showed displacement > 40%.

Hagglund, G., Lauge-Pederson, H., and Wagner, P., (2007), Characteristics of children with hip displacement in cerebral palsy. BMC Musculoskelet Disord, Oct (26)8,101.

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Femoral Anteversion and CP

• 147 children (267 hips) of children with CP studied.

• Early ages, angle of femoral anteversion similar to typically developing peers.

• As age, typical children’s angles decreased to normal adult degrees.

• CP children showed minimal change in degree of anteversion.

Bobroff,ED; Chambers,HG et.al.(1999), Femoral anteversion and neck shaft angle in children with cerebral palsy. Clin Orthop Relat Res, July (364), 194-204.

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Coxa Valga

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(Image removed due to copyright policy)


Who Is At Risk?

• GMFCS Levels IV and V are highest risk.

• Level III lesser risk but need monitoring.

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• 1. Asymmetries:

– Muscle Imbalances

– Range of motion limitations, especially at hips and knees.

– Spasticity

– Adduction contractures can directly lead to changes in the acetabulum and femur.

2. Lack of Normal Weight Bearing

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Risk Factors


Intervention

• 1. Tone Management

• 2. Postural management

• 3. Therapy

• Orthoses and Splinting

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Postural Management

• Level 4 evidence suggests that use of postural management concepts and equipment before the age of 18 months, can decrease incidence of hip pathology in CP children at GMFCS Levels III, IV andV.

Pountney,T, Mandy,A et.al.,(2009), Hip subluxation and dislocation in cerebral palsy-a prospective study on the effectiveness of postural management programmes. Physiother Res Intl, June(14)Issue 2, 116-127.

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Positioning

• The following areas need to be addressed:

– Lying Support

– Seating

– Standing

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Standing

• Goal:

– Symmetry

– Neutral pelvis in terms of tilt, rotation and obliquity

– Hips in ABDUCTION

– Hips and knees in full extension

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Why Abduction?

• (Image removed due to copyright policy)


Martinsson and Himmelmann

• Non-ambulatory children with CP, GMFCS levels III-V.

• 1 year of straddled weight bearing in maximumtolerated hip extension and abduction.

• Controls matched for age, motor ability and surgery.

Martinsson, C., Himmelmann, K., (2011), Effect of weight bearing in abduction and extension on hip stability in children with cerebral palsy, Pediatr Phys Ther, Summer 23(2), 150-157.


Dosing

• 1. Bone Mineral Density – 60-90 minutes/day

• 2. Hip Stability – 60 minutes in 30-60 degrees bilateral hip abduction.

• 3. Range of Motion of Hip Knee and Ankle – 45 to 60 minutes.

• 4. Spasticity – 30 to 45 minutes.


Systematic Review Dosage

Paleg, G., Smith, A., Glickman, L., (2013), Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Ped Phys Ther, 25, 232-247.

Paleg, G., Livingstone, R., (2015), Systematic review and clinical recommendations for dosage of supported home-based standing programs for adults with stroke, spinal cord injury and other neurological conditions. BMC Musculoskeletal Disorders, 16:358.


Sitting

• Goal:

– Symmetry

– Neutral pelvis in terms of tilt, rotation and obliquity.

– Hips in ABDUCTION

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Lying

• Symmetry

• Hips in Abduction

• Comfort

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When Equipment Considered

• Lying Supports – As soon after birth as possible.

• Sitting programs – About age 6 months.

• Standing – Age 10 to 12 months.

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Positioning Children GMFCS Levels IV-V

Supine – Sunny Hill Health Centre

Use positioning rolls, wedges, bolsters that hold shape.

Use daily to tolerance. Avoid asymmetry.

• Ages 0 to 2 - 15 to 30 degrees hip abduction, hip flexion 10 to 40 degrees, hip external rotation 5 to 30 degrees.

• Ages 2 to 4 – Hip abduction to 20 degrees, flexion 0 to 15 degrees, external rotation 5-15 degrees.

• 6 and Over – Hip abduction 20 degrees, flexion 0-10, external rotation 5-15.

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Sitting – Sunny Hill Health Centre

Aim for hip abduction 15 to 30 degrees. Hip external rotation 5 to 15 degrees.

Infants – Introduce about age 5 months to tolerance. Gradually bring to more upright to encourage head control. May adapt commercially available baby equipment.

2 and Older – Use for feeding, fine motor activities, interaction and mobility. Ages 2 to 6, up to 6 hours a day. Older than 6, 6 hours or more to tolerance.

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Standing – Sunny Hill Health Centre

• Use supine, prone, upright or sit to stand standers.

• Under 2 – Introduce about age 10 months. Aim toward 15 + degrees hip abduction. Daily per tolerance.

• Ages 2 and Older – Hip abduction 15 to 30 degrees.Avoid 0 degree hip abduction. Use daily 60 to 90 minutes.

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Walking – Sunny Hill Health Centre

Supportive Walker/Gait Trainer

• Introduce for Level IV children after 10 months as appropriate.

• Provide support where needed from head down.

• Aim for active range of motion.

• Daily as per tolerance.

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24 Hour Postural Care

• Literature shows strong correlation between postural asymmetries and hip displacement, scoliosis, kneeflexion contractures.

• At least 1/3 of 24 hour day, is spent lying down/sleeping.

• Basis of this approach is to support the person in comfortable, well aligned, symmetrical positionthroughout day and night.

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Montana Postural Care Project

• Pilot program funded by the Montana Council onDevelopmental Disabilities.

• Purpose: “Introduce 24 hour postural care as apractical approach for people with motor impairments in a large rural state with limited special services, while examining the results in the population served.”

Tamara Kittleson-Aldred, (2017), Montana Postural Care project: a 24 hour postural care model, Proceedings of the 33rd International Seating Symposium, Mar 2-4, 2017.

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Montana Project

• Participants: 30 people with physical impairments/spasticity.

• Training: 1 day course for all participants including therapists, caretakers, nurses, etc.

• Evaluation: Half day in home for each individual person in study. Included Goldsmith Indices of Bodysymmetry (GIoBS), Pittsburgh Sleep Quality Index, Pediatric Pain Profile or other pain scale.

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Montana Project

• Night Time Care Plan formulated.

• Provided: 4 postural supports

– Non-slip mesh

– Pressure relieving airflow mattress pad

– 2 types lateral supports (usually included a leg positionerof some kind)

– Additional household items (rolled towels, stuffed animals, cushions)

Photos Taken --- Ongoing support as needed.

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Montana Project

• Results:

– 80% improvement sleep quality vs. 0% controls.

– 80% improved body symmetry vs. 0% controls.

– 50% participants with pain issues, had lower pain scores.

• Anecdotal:

– Most common report was improved day time alertness.

– Several people who did not tolerate the full posturalassessment at initial evaluation, tolerated at final follow up.

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Surveillance

• Whole child oriented

– Includes tone management, gross and fine motor development, hip and spine surveillance.

• Levels III to V GMFCS - Ortho

– Radiographs hips annually starting 1 year to 8 years.

– After 8, radiographs as needed.

– MP calculated all radiographs

– CPUP Hip Score

– Hips at risk dislocation, MP > 40% surgery considered early.

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Surveillance - Therapy

• Evaluation 2 times/year until age 6, then annually

• Evaluation includes joint range of motion using agoniometer, and clinical evaluation of spine.

• Goal: early detection of contractures and deformities to allow for early non-surgical treatments.

• Treatment includes:

– Postural management

– Orthotics and assistive devices

– Individual training

– Spasticity management

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CPUP Program

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Equipment Options and Positioning Recommendations …/media/files/Childrens/medical-professionals/... · Equipment Options and Positioning Recommendations to ... Glickman, L., (2013),