Hip Surveillance for Children with Cerebral Palsy:

From Diagnosis to Discharge

Stacey Miller, BSc (PT), MRSc

October 19, 2018
 Objectives
▪ Describe hip displacement in children with
cerebral palsy.
▪ Understand the rationale for hip surveillance
and supporting evidence.
▪ Discuss current practice of hip surveillance in
BC and the role of the pediatrician.
 Hip Displacement
▪ Gradual lateral movement of the femoral head from
under the acetabulum

Normal hip alignment Hip displacement & dislocation

 Measuring Migration
Reimer’s Migration percentage: A/B * 100%
 Hip Displacement in CP

Early stage Displacement Displacement Dislocation

& bony changes

1 in 3 children with CP have hip displacement

(Hagglund et al., 2007; Kentish et al., 2011; Soo et. al, 2006; Terjesen, 2012)
GMFCS:
Gross Motor Function
Classification System
Displacement (%)
Incidence of Hip
Risk Factors

GMFCS Level

(Soo et. al., JBJS 2006; 88-A (1): 121-9)

 Cause of Hip Displacement
• Delayed weight-bearing and abnormal muscle
forces around the hip

• Changes in the proximal femur

• Increased femoral anteversion
• Increased femoral neck-shaft angle

• Not related to type of movement disorder

Persistent Femoral Anteversion

10o
35o
Femoral
Anterversion
Birth 35-40o
GMFCS I 30o
GMFCS II 36o
GMFCS III 40o
GMFCS IV 40o
GMFCS V 40o
Robin et al. 2008
Birth: 35-40o Skeletal Maturity: 10-15o
 Increased Neck Shaft Angle

Neck Shaft Angle

Birth 135-140o
GMFCS I 136o
GMFCS II 141o
GMFCS III 149o
GMFCS IV 155o
GMFCS V 163o
Robin et al. 2008

Birth: 135-40o Coxa Valga: 160o

Skeletal Maturity: 125o
 Consequences

Early stage Displacement Displacement Dislocation

& bony changes

Pain
Decreased quality of life
Loss of mobility
Loss of ROM
More complex surgery
 Consequences: Pain
• Investigated characteristics of pain in children/youth with CP,
aged 3-19
• 252 participants
• 54.8% of participants reported some pain
• Physicians reported pain in 38.7%
• Physicians identified hip subluxation/dislocation as the most
common cause of pain

Penner et al., Pediatrics. 2013;132:e407

 Consequences: Pain
• 77 children, GMFCS III-V, mean age 9.5 (SD 1.6) years from
population-based Norwegian CP register
• Caregivers responded to the Child Health Questionnaire pain
questions and located recurrent pain on a body map
• 29% of children reported to have hip pain
• MP ≥ 50% was significantly associated with hip pain (p = 0.01)

Ramstad & Terjesen. J Pediatr Orthop B 2016; 25(3): 217-21.

Consequences: Reduced QOL
 Consequences: Mobility
GMFCS IV GMFCS V

Age 14 years Age 11 years

 Consequences: Mobility
GMFCS II GMFCS II

Age 17 years Age 22 years

 Treatment
Depends on:
▪ The extent of hip displacement
▪ Secondary bony changes
▪ Pain
▪ Age
▪ The child and family
Surgical Intervention: Preventive
Soft-tissue release
• Adductor longus release
• Gracilis release
• Adductor brevis release
• Iliopsoas lengthening
• Obturator neurectomy
 Surgical Intervention: Reconstruction

Pre-operative Post-op: Bilateral varus derotation osteotomies

and right pelvic oblquity
• Preop: higher MP associated with decreased HRQOL
• Postop: lower MP associated with increased HRQOL
Surgical Intervention: Salvage Procedure

Femoral head resection Femoral head resection and valgus osteotomy

 Treatment
Depends on:
▪ The extent of hip displacement noted
▪ Secondary bony changes
▪ Pain
▪ Age
▪ The child and family

Early detection = Treatment options remain open

Hip Displacement: BC Experience
80
70 BCCH - 2008/09
60
Melbourne
50
40
30
20
10
0
Preventive Reconstructive Salvage
 Hip Surveillance
• Identify and monitor early indicators of hip displacement by
an active screening program

• Aim: refer to a pediatric orthopedic surgeon at the

appropriate time

• 2 components: clinical and radiological exams

• Frequency is based on risk

• Dislocation rate
• 8% historical control group (n = 103) (born 1990-1991)
• 0.5% in children born 1992-1997 (n = 258)
• 0% in children born 1998-2007 (n = 431)
• Conclusion: a population-based hip surveillance program
enables the early identification and preventive treatment

Hagglund et al., 2014

• Enrolled 1,115 children (73% of expected)
• No child has progressed to dislocation while on surveillance without
orthopedic review
• Successful at:
• Correctly identifying children with hip displacement
• Fast tracking children for orthopedic review
• Discharging those at minimal risk
• Preventing silent hip dislocation
Kentish et al., 2011
 Building Consensus in BC: May 2011
▪ 50 participants
▪ All regions represented
▪ Inter-disciplinary
• Pediatric orthopaedic surgeons
• Pediatricians
• Developmental Pediatricians
• GPs
• Physiotherapists
• Occupational Therapists
• Nurse
• Radiology
• Health administrators
• Policy makers
• Parents
Hip Surveillance
AACPDM Care Pathway Team
• Robyn Cairns, Vancouver BC, Pediatric Radiology
• Kerr Graham, Melbourne Australia, Pediatric Orthopedics
• Sarah Love, Perth Australia, Physical Therapy
• Tanja Mayson, Vancouver Canada, Physical Therapy (Project Manager &
subgroup lead)
• Freeman Miller, Wilmington Delaware, Pediatric Orthopedics
• Stacey Miller, Vancouver Canada, Physical Therapy (sub-group lead)
• Kishore Mulpuri, Vancouver Canada, Pediatric Orthopedics
• Maureen O’Donnell, Vancouver Canada, Developmental Pediatrics
(Project Lead)
• Unni Narayanan, Toronto Canada, Pediatric Orthopedics
• Heather Read, Glasgow Scotland, Pediatric Orthopedics
• Ben Shore, Boston USA, Pediatric Orthopedics
• Kate Stannage, Glasgow Scotland, Pediatric Orthopedics
• Pam Thomason, Melbourne Australia, Physical Therapy
• Jilda Vargus-Adams, Cincinnati, USA, Pediatric Physiatry
• Laura Wiggins, Glasgow Scotland, Physical Therapy
• Kate Willoughby, Melbourne Australia, Physical Therapy
• Meredith Wynter, Brisbane Australia, Physical Therapy
Implementation in BC

Child Development Centers

School Services

Pediatric Orthopaedic Surgeons

Hip Surveillance
Coordinator/Medical Lead
 Clinical Exam
• GMFCS level
• Motor distribution
• Group IV Gait
• Motor type
• Hip abduction
• Question re: pain
• Pain on clinical exam
 Radiological Exam
• AP pelvis (supine) – “CP – Hip Surveillance”
• Positioning
– Abduction/adduction: Neutral
– Hip rotation: Patellae up
– Neutral Pelvic Obliquity; Flattened lordosis
• Measure: Migration Percentage (MP)

Reproduced with permission and copyright

© Bill Reid, Royal Children’s Hospital, Melbourne, Australia.
 Referral to Orthopaedics
• MP >30% on AP pelvis
• Hip abduction ROM < 30o
• Pain on clinical exam
• Pain on parent report
 Discharge from Surveillance
• GMFCS level I: age 5 if no concerns
• GMFCS level II: age 10 if no concerns
• GMFCS Ievels III to V & Type IV gait
• Skeletal maturity in high risk groups
• MP < 30%
• No concerns re: pelvic obliquity and/or scoliosis
• Launched in September 2014
• Goal:
• Establish a province-wide, consistent standard of care for hip
surveillance
• Support the learning needs of community therapists and families
• Ensure referral to a paediatric orthopaedic surgeon occurs at the
appropriate time to minimize or prevent complications associated with
hip dislocations
 Phase 1 Work
▪ Creation of communication and knowledge translation plan
▪ Determination of service providers
▪ Completion of a knowledge and needs survey
▪ Creation of knowledge translation materials
▪ Creation of Advisory Committee
▪ Development of a data management system
▪ Development of an evaluation plan
 Resources
• Parent booklets (6 languages)
• Clinician booklet
• E-learning module
• Frequently Asked Questions
• Launch Checklist
• Radiology Information Sheet
• Quick Guide
• Enrollment forms and pathway
• You-Tube Video
• Webinar
www.childhealthbc.ca/hips
 Provincial Roll Out

Feb 2016 :
Sep 2014: Add 2 test
Launch Phase 1 sites

Sep 2015: Aug 2016:

Enroll at BCCH Provincial
roll out
 Current State
800 765
700

600
Number Enrolled

500

400

300
Test sites
200

100

0
Provincial Launch

Updated: August 31, 2018

 Current State
GMFCS GMFCS GMFCS GMFCS GMFCS Total
I II III IV V
Total 150 171 106 167 171 765

Discharged 87 57 11 21 22 198

Active 63 114 95 146 149 567

Group IV
12 15 1
Gait

Updated: August 31, 2018

 Current Enrollment by Age
80

70

60
Number of Children

50

40

30

20

10

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Birth Year
Enrollment up August 31, 2018
 Current State
Comparison of Enrollment by Age
1600

1400
Enrolled Expected

1200
Number of children

1000

800

600
31%
400 46%
200

Under 6 (2012 to 2015) School Aged (2000 to 2011)

Enrollment up August 31, 2018

 Current Status
Child Health BC Hip Surveillance Program Enrollment by GMFCS

700

Enrolled
600
Expected 2-17 years
Number of Children Enrolled

500

400

300

24% 66% 37% 37%

200
27%
100

0
I II III IV V

GMFCS Level

Enrollment up August 31, 2018

Enrollment by Health Authority
Enrollment by Local Health Authority Compared to Expected
September 15, 2015 to August 31, 2018
1000

900
Enrolled
800
Estimated Population
Number Enrolled

700
2000-2016
600

500

400
37%
300
44%
200
18% 41% 51%
100

VCH FHA IHA VIHA NHA

Health Authority

Enrollment up August 31, 2018

What are the barriers, if any, to keep you from enrolling children in the Hip
Surveillance Program?
Number of Responses
0 5 10 15 20 25 30

There is no one who is appropriate on my caseload

I don't know who is appropriate

I think the child is appropriate but they don't have a

diagnosis of CP
Family physician or pediatrician didn't support
enrollment into program

I haven't found the time

Parents don't agree with enrollment

I don't have the space to complete the clinical exam

I don't think its my responsibility

Other

None of the above

Due to the length of time children have to wait (over
19 mo) to see a pediatric neurologist in our area ALL
of the children I wish to refer do not have a
diagnosis yet. Some of these kids are almost 4 and
have just shown up on my case load. The family
doctors are hesitant for us to give out brochures due
to the label of CP in them without the diagnosis.

- Early Intervention Physiotherapist

September 19, 2018
 Definition of Cerebral Palsy
“a group of permanent disorders of the development of
movement and posture, causing activity limitation, that are
attributed to non-progressive disturbances that occurred in the
developing fetal or infant brain. The motor disorders of cerebral
palsy are often accompanied by disturbances of sensation,
perception, cognition, communication, and behaviour, by
epilepsy, and by secondary musculoskeletal problems”.(p. 9)

(Rosenbaum et al. Dev Med Child Neurol. 2007;49:8-14)

 Definition of Cerebral Palsy
▪Not defined by the underlying etiology
▪Includes:
▪ Children with a genetic anomaly
▪ Chromosomal abnormality
▪ Metabolic condition
▪ Acquired brain injury from meningitis, encephalitis, or
a stroke in early life
 Pediatrician Survey
• 2018 Survey of BC Pediatricians
• 78 Responses
• 62% Metro (pop over 190,001)
• 29% Urban/Rural (pop between 40,001-190,000
• 8% Rural (pop 10,001-40, 000)
• 1% Remote (pop < 10,000)
• 46 (60.5%) General Pediatricians
 Pediatrician Survey Results
Please estimate the percentage of the children in your practice who have cerebral palsy.
Number of Responses

Percentage of Caseload with CP

 Pediatrician Survey Results
Please estimate the number of children with cerebral palsy that you see in your clinic in an
average month. (Consider the last month)
35
Number of Responses

30

25

20

15

10

Number of children with CP

seen in an average month
 Pediatrician Survey Results
Abnormal brain imaging is required for a diagnosis 6.9%
of cerebral palsy. 93.1%
Cerebral palsy is an umbrella term that is not 91.4%
defined by etiology. 8.6%
Of all children with cerebral palsy, 40% are born 67.2%
prematurely and 60% are born at term. 32.8%
Predicting severity of cerebral palsy is most accurate 86.2%
after age 2 years. 13.8%
A diagnosis of cerebral palsy can only be made when 1.7%
the cause of the child’s motor impairment is known. 98.3%
Evidence supports the early diagnosis of cerebral 84.5%
palsy. 15.5
0 10 20 30 40 50 60 70 80 90 100
Percentage

TRUE FALSE
 Pediatrician Survey Results
Genetic cause 72%
Periventricular leukomalacia 97%
Spinal nerve injury 67% FALSE
ABI during the first 2-3 years of life 83%
Chromosomal 71%
Metabolic condition 74%
Muscular origin 74% FALSE
Cerebral malformation 86%
Infection (meningitis/encephalitis) 88%
Unknown etiology 88%
0% 20% 40% 60% 80% 100%
Percentage
 Current Practice: Diagnosis
Are you currently diagnosing children with cerebral palsy
in your practice?

• 45 General Pediatricians
• 27 (60%) Yes
• 15 (33%) No
• 2 (4%) reported 0% of practice is children with CP
• 1 (2%) did not respond
 Pediatrician Survey Results
Of the following providers, who do you think can make a definitive
diagnosis of cerebral palsy? Please check all that apply.

Pediatrician 90%

Developmental pediatrician 93%

Neurologist 98%

Family physician 32%

Orthopaedic surgeon 45%

Other: physiotherapist 7%

0% 20% 40% 60% 80% 100%

 Enrollment Process

Provider Referral Form

www.childhealthbc.ca/hips
 Conclusion
• Hip surveillance is internationally recognized as
important
• Early identification and diagnosis of cerebral
palsy is important
• Pediatricians play a major role
• What can we do to support you?

Thank you for supporting the program.

THANK YOU
hips@cw.bc.ca
www.childhealthbc.ca/hips