Stand up and be counted

Abstract

This commentary is on the original article by Rodby-Bousquet et al. on pages 1009-1015 of this issue.Cerebral palsy (CP) arises from a non-progressive brain injury, resulting in life-long physical disability; but owing to the co-occurring musculoskeletal impairments, deterioration in gross motor abilities ensues during the adolescent years. 1 The natural history also involves three in four individuals experiencing chronic pain; one in three experiencing hip displacement; one in ten experiencing scoliosis; and almost all experiencing some contracture, further compounding their physical disability.2 The highest rates of co-occurring limitations are amongst non-ambulatory individuals with bilateral involvement, with the exception of pain, which is likely to be present at all levels of physical disability. 2Fortunately 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. Surveillance interventions typically include botulinum toxin, selective dorsal rhizotomy, intrathecal baclofen, and intensive therapy.5 Moderate quality evidence confirms that active surveillance can reduce the rate of hip dislocation from an expected 7.5% (95% CI 7-8) to a staggering 0%.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).From the Swedish register, Rodby-Bousquet et al. 6 report total population data on adult postural asymmetries, providing us with insights of great consequence about long-term musculoskeletal management. First, the data provide new level 1 evidence that postural asymmetries are present in almost all adults with CP; although those who can stand have lower rates of asymmetry than those with more severe physical disability. The data also clearly show that postural asymmetries are the precursors to contracture, deformity, and inability to change position. In knowledge translation terms, the identification of postural asymmetry should be the red flag to screen for contracture, since a great deal of deformity can be prevented via active surveillance.Second, and most disconcertingly, Rodby-Bousquet et al.'s data provide new level 1 evidence that 50% of adults at Gross Mo...

Postural asymmetries, pain, and ability to change position of children with cerebral palsy in sitting and supine: a cross-sectional study

“…Nevertheless, we identified postural asymmetries also in the youngest children. This is consistent with findings by Fulford and Brown [27] and Porter et al [6] and may indicate that postural asymmetries may originate early in childhood. The results support the need for early postural interventions to monitor range of motion (ROM) and the development of postural asymmetries from an early age, and continuously throughout life [4,27].…”

“…This is consistent with findings by Fulford and Brown [27] and Porter et al [6] and may indicate that postural asymmetries may originate early in childhood. The results support the need for early postural interventions to monitor range of motion (ROM) and the development of postural asymmetries from an early age, and continuously throughout life [4,27]. The presence of postural asymmetries remains a concern, as previous studies have reported how they most likely result in soft tissue adaption, contractures, further postural deformities [4,7,12,20] and pain [28].…”

Psychometric evaluation of the Posture and Postural Ability Scale for children with cerebral palsy

“…1–4 Most of these deformities can be prevented via active surveillance and therefore identification of asymmetries and postural deficits should be used to screen for contractures. 5–9…”

“…[1][2][3][4] Most of these deformities can be prevented via active surveillance and therefore identification of asymmetries and postural deficits should be used to screen for contractures. [5][6][7][8][9] The Posture and Postural Ability Scale (PPAS) 10 is the only clinical assessment tool designed to assess 'quality' and 'quantity' of posture separately, in the four basic body positions: supine, prone, sitting and standing. 'Quality' of posture, relates to the shape of the body, that is, the particular alignment of body segments in relation to each other and to the supporting surface.…”