Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity

Abstract

During the 1990s three new techniques to reduce spasticity and dystonia in children with cerebral palsy (CP) were introduced in southern Sweden: selective dorsal rhizotomy, continuous intrathecal baclofen infusion and botulinum toxin treatment. In 1994 a CP register and a health care programme, aimed to prevent hip dislocation and severe contractures, were initiated in the area. The total population of children with CP born 1990-1991, 1992-1993 and 1994-1995 was evaluated and compared at 8 years of age. In non-ambulant children the passive range of motion in hip, knee and ankle improved significantly from the first to the later age groups. Ambulant children had similar range of motion in the three age groups, with almost no severe contractures. The proportion of children treated with orthopaedic surgery for contracture or skeletal torsion deformity decreased from 40 to 15% (P = 0.0019). One-fifth of the children with spastic diplegia had been treated with selective dorsal rhizotomy. One-third of the children born 1994-1995 had been treated with botulinum toxin before 8 years of age. With early treatment of spasticity, early non-operative treatment of contracture and prevention of hip dislocation, the need for orthopaedic surgery for contracture or torsion deformity is reduced, and the need for multilevel procedures seems to be eliminated.

Preoperative gait analysis has a substantial effect on orthopedic decision making in children with cerebral palsy: Comparison between clinical evaluation and gait analysis in 60 patients

“…Botulinum toxin A injections can delay and even reduce the need for surgery (Koman et al 1999, Hägglund et al 2005). In addition, methods of physiotherapy and orthotic intervention have undergone improvements (Gage and Quanbeck 2004).…”

Stand up and be counted

“…2 Fortunately for patients, evidence-based solutions exist. Seminal work by H€ agglund et al 3,4 at the Swedish Cerebral Palsy Register demonstrates that some of the natural history can be averted using active surveillance. Active surveillance involves regular and systematic assessment of people with CP to detect any natural history deteriorations (6-monthly <6y and annually >6y) paired with timely revision of multidisciplinary treatment plans to redress any decline observed.…”

“…4 On the strength of this evidence, it follows that evidence-based care worldwide must comprise active surveillance for all children with CP. Australia, Canada, Denmark, Norway and Sweden all have hip surveillance guidelines, and for countries without guidelines many of these tools are freely available online to support the provision of evidence-based care (ausacpdm.org.au).…”

“…2 What is more, when active surveillance is applied to the total CP population, the call for orthopaedic surgery to reduce contractures, correct foot and rotational deformities, and salvage hips, falls dramatically from 40% to 15%. 4 On the strength of this evidence, it follows that evidence-based care worldwide must comprise active surveillance for all children with CP. Australia, Canada, Denmark, Norway and Sweden all have hip surveillance guidelines, and for countries without guidelines many of these tools are freely available online to support the provision of evidence-based care (ausacpdm.org.au).…”

Unilateral varus osteotomy of the proximal femur in children with cerebral palsy: A five-year follow-up of the development of both hips

“…In 1994, a CP register and a healthcare programme, known as CPUP, were initiated for children with CP in southern Sweden (1.4 million inhabitants) [7,8]. In the programme, all children are regularly examined clinically and radiographically.…”