Cerebral Palsy Integrated Pathway (CPIP) of hip surveillance, for children with non- Cerebral Palsy diagnosis?

Purpose

The Cerebral Palsy (CP) Integrated Pathway (CPIP) has made recent advances with patient management systems being implemented. CPIP aims to detect changes in muscles and joints particularly of the lower limbs for the early treatment of hip subluxation and reduction of salvage surgeries of the hip in children with CP, Gross Motor Function Classification System (GMFCS) level`s I-V.

Physiotherapists conduct the physical examination according to a standardised assessment regime. This is accompanied by repeat surveillance x-rays of the hips according to the x-ray schedule.

The increasing risk of hip dysplasia in children with CP resulted in the impetus for a clinical audit being performed to establish the hip status for all children with neuromuscular/ neurodisability not classified strictly as CP but equally with abnormal or absent mobility, as classified by the GMFCS level.

VDRO was recommended, planned or completed in 4/13 cases
highlighting the need to monitor hips of children with a non-CP neuromuscular / neurodisability diagnosis and limited ambulation.

Approach

This is a retrospective clinical audit. Data from a one-month period will be presented.

Children were included in the audit if their primary diagnosis was of neuromuscular origin but CP was not their diagnosis. The child`s medical notes were searched for all given diagnoses, to exclude a secondary CP diagnosis.

GMFCS equivalent scores were collected for descriptive purposes of the child`s gross motor function. X-rays were reviewed if they were available and progress over time recorded.

Outcomes

The audit was conducted from the 25th of February to 15th of April 2019 including three Consultant led and three Physiotherapist lead clinics for Neuro-orthopaedics per week.


A total of 13 patients aged between 2 years and 14.6 years were identified. They did not have a diagnosis of CP. None were classified as GMFCS I or II, two were classified as GMFCS III, two as GMFCS IV and eight as GMFCS V.


Seven out of eight children classified as GMFCS V presented with either bilateral or unilateral hip displacement of varying degrees.

One child had a hip dislocation on the left but due to poor prognosis surgery was not an option, one child was offered varus derotation osteotomy (VDRO) but parents did not consent, and five were monitored with stable hip displacement. One was monitored for other concerns, presenting with normal hips. Both children classed as GMFCS IV had VDROs. One of the children with GMFCS III was booked for VDRO surgery and the other is on a monitoring pathway.

VDRO was recommended, planned or completed in 4/13 cases, highlighting the need to monitor hips of children with a non-CP neuromuscular / neurodisability diagnosis and limited ambulation.


Although further research is needed to describe the relationship between tone, GMFCS level and diagnosis, it is important to note that children with other non-CP neuromuscular/ neurodisability diagnoses equally present with hip displacement. These children require on-going hip surveillance monitoring clinically and radiologically.

Implications

Implementation of the CPIP assessment schedule for these children might enhance early detection of hip displacement and treatment and further research in this area is warranted.

Funding acknowledgements

No funding was received for this particular project. 

Additional notes

This work was presented at Physiotherapy UK 2019.