Wednesday, January 25, 2017

Management of Scoliosis in Children with Cerebral Palsy

Management of Scoliosis in Children with Cerebral Palsy

The Journal of Spine Surgery published an open access review on the management of scoliosis in children with cerebral palsy (CP). Research indicates that 21-64% of children with CP develop scoliosis most likely to occurring before 10 years of age.  In children with CP, scoliosis can progress beyond skeletal maturity which is different from idiopathic scoliosis.

The development of scoliosis is related to the the child’s level of disability.  Research indicates the following:

  • statistically significant relationship between Gross Motor Function Classification System (GMFCS) level and development of scoliosis with 50% of children GMFCS IV–V developing a severe scoliosis.
  • Cobb angle of greater than 40 degrees at an early age has been found to predict significant progression of a CP scoliosis.
  • inverse relationship between development of scoliosis and ambulation with the least mobile children at greatest risk.

The rate of progression of scoliosis varies:

  • in the adult, largely non ambulatory population, progression can range between 3.0 – 4.4 degrees per year.
  • according to size of curve; larger curves (>50 degrees) have been shown to progress almost twice as fast than smaller curves.
  • curves were most likely to progress GMFCS IV and V.

There are two patterns of scoliotic curves in individuals with CP:

  • Group-I curves can be considered double curves with a thoracic and lumbar component and occurred most often in ambulatory patients, with minimal pelvic obliquity.
  • Group-II curves are single curves in either the thoracic or lumbar spines and were of greater magnitude. They occur more frequently in quadriplegic patients and almost all display significant pelvic obliquity.

There are several approaches to the non-surgical management of scoliosis in children with CP:

  • Bracing – there is mixed evidence to support this approach.  There is evidence to support bracing to assist with sitting balance and trunk support, providing better control of the head, neck and arms.   Some research suggests bracing may slow curve progression, particularly in younger patients with curves less than 40 degrees.  Although other research has reported limited success and recommend bracing as an interim measure before surgical correction.
  • Seating and positioning has been shown to provide increased support and improve functional outcomes although there are limited studies on the specific effects of seating systems on correction of spinal deformity.  One study indicated that the placement of a 3-point system of lateral support pads was shown to offer a more symmetrical trunk posture and correct curve angles by 35% in non-ambulatory CP patients with scoliosis.
  • Botulinum toxin injection – one small study indicated that it did not worsen scoliosis and provided some reduction in magnitude of the curve in all patients.
  • Intrathecal baclofen (ITB) – there is conflicting evidence regarding ITB pumps.  Some research indicated a significant increase in Cobb angle was observed following ITB pump insertion although other studies have shown there to be no difference in progression of scoliotic curves.

Currently, research indicates that surgery is the only option for the definitive management of scoliosis in CP.   The goal of surigcal correction is a balanced spine, prevention of curve progression and improvement in quality of life.   Surgery should be considered in individuals with CP who have:

  1. large curves (>50 degrees).
  2. scoliosis progressing beyond skeletal maturity.
  3. significant curves resulting in functional or physiological disturbance.

Following surgical correction, outcomes are varied.  Survey following surgery indicate a high level of satisfaction with up to 99% of parents being satisfied with the outcome of the procedure with 85–94% willing to consider surgical intervention for their children again.  Although other research suggests that surgery provides no improvement in function, school attendance or co-morbidities but improvement in postoperative quality of life has been reported.  There is high risk of postoperative complications following surgical correction.

The decision making for the management of scoliosis in children with CP should be on an individual basis, with involvement of the physician, child, family and wider members of the multi-disciplinary team.

Reference:  Cloake, T., & Gardner, A. (2016). The management of scoliosis in children with cerebral palsy: a review. Journal of Spine Surgery, 2(4), 299-309.  Read the full text here

Teaching Motor Skills to Children with Cerebral Palsy and Similar Movement Disorders - A

Teaching Motor Skills to Children with Cerebral Palsy and Similar Movement Disorders – A Guide for Parents and Professionals is a must have reference for all therapists who work with children with cerebral palsy. Whether you are a beginner or experienced therapist you will find the information concise, informative and very helpful to carry out everyday functional tasks including stretching with children with cerebral palsy. The book provides activity suggestions throughout the developmental sequence such as head control, tummy time, sitting, transitions, walking and beyond. There is also great information that reviews additional interventions for children with cerebral palsy such as bracing, surgical and medical management. The author, Sieglinde Martin, is an experienced PT and a mother of a child with cerebral palsy.  Find out more information.

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