Incidence of scoliosis in cerebral palsy.

Background and purpose - Surveillance of scoliosis in individuals with cerebral palsy (CP) is important for ensuring timely diagnosis and identification of curve progression. We analyzed the incidence of scoliosis in relation to age, sex, and gross motor function in a population-based cohort of individuals with CP. Patients and methods - This was a prospective register study of all 1,025 individuals born 1990-2012 in southern Sweden (1.4 million inhabitants) in the Swedish surveillance program for CP, which included >95% of the total population of people with CP in the area. Annual clinical examinations and radiographic measurement of the Cobb angle of those with a moderate or severe scoliosis were registered. We determined the incidence of scoliosis related to age, sex, and the Gross Motor Function Classification System (GMFCS) level. Results - The inclusion criteria were fulfilled by 962 individuals. The number of people (140/962) with scoliosis increased up to 20-25 years of age. The incidence of scoliosis was related to age and GMFCS level. In individuals at the lowest level of gross motor function (GMFCS V) scoliosis was seen in 10/131 before 5 years of age and at the age of 20 years 75% of these individuals had a Cobb angle ≥40°. No one in the highest level of motor function (GMFCS I) developed a Cobb angle ≥40° Interpretation - Surveillance programs for scoliosis in CP should be based on age and GMFCS level and should be initiated at a young age and continued into adulthood.

Windswept hip deformity in children with cerebral palsy: a population-based prospective follow-up.

PURPOSE: To analyze the development of windswept hip deformity (WS) in a total population of children with cerebral palsy (CP) up to 20 years of age, the association between WS and hip dislocation, and femoral varus osteotomy and scoliosis, and the impact of a hip surveillance program on the subsequent incidence of WS. METHODS: This is a prospective study on children with CP in southern Sweden included in the Swedish follow-up programme and registry for CP (CPUP). All children born between 1990 and 1995 with CP were included; those born between 1990 and 1991 did not partake in the hip surveillance program until they were older (3-5 years of age) and served as a historic control group. Children born between 1992 and 1995 were included in the hip surveillance program from about 2 years of age and constituted the study group. RESULTS: In the control group, 12 of 68 children (18 %) developed WS. In the study group of 139 children, 13 (9 %) developed WS (p = 0.071). Of all 25 children with WS, 21 also developed scoliosis and 5 developed a hip dislocation. The number of children with WS starting in the lower extremities was significantly lower in the study group (p = 0.028). No difference between the two groups was seen regarding WS that started in combination with scoliosis. CONCLUSION: With early inclusion in a hip surveillance program and early treatment of contractures, it appears possible to reduce the frequency of WS starting in the lower extremities.

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

OBJECTIVE: To evaluate construct validity, internal consistency and inter-rater reliability of the Posture and Postural Ability Scale for children with cerebral palsy. DESIGN: Evaluation of psychometric properties. SETTING: Five child rehabilitation centres in the south of Sweden, in November 2013 to March 2014. SUBJECTS: A total of 29 children with cerebral palsy (15 boys, 14 girls), 6-16 years old, classified at Gross Motor Function Classification System (GMFCS) levels II (n = 10), III (n = 7), IV (n = 6) and V (n = 6). MAIN MEASURES: Three independent raters (two physiotherapists and one orthopaedic surgeon) assessed posture and postural ability of all children in supine, prone, sitting and standing positions, according to the Posture and Postural Ability Scale. Construct validity was evaluated based on averaged values for the raters relative to known-groups in terms of GMFCS levels. Internal consistency was analysed with Cronbach's alpha and corrected Item-Total correlation. Inter-rater reliability was calculated using weighted kappa scores. RESULTS: The Posture and Postural Ability Scale showed construct validity and median values differed between GMFCS levels (p < 0.01). There was a good internal consistency (alpha = 0.95-0.96; item-total correlation = 0.55-0.91), and an excellent inter-rater reliability (kappa score = 0.77-0.99). CONCLUSION: The Posture and Postural Ability Scale shows high psychometric properties for children with cerebral palsy, as previously seen when evaluated for adults. It enables detection of postural deficits and asymmetries indicating potential need for support and where it needs to be applied.

Psychometric evaluation of spinal assessment methods to screen for scoliosis in children and adolescents with cerebral palsy.

BACKGROUND: In cerebral palsy (CP) there is an increased risk of scoliosis. It is important to identify a progressive scoliosis early-on because the results of surgery depend on the magnitude of the curve. The Swedish follow-up program for cerebral palsy (CPUP) includes clinical examinations of the spine. The reliability and validity of the assessment method have not been studied. In this study we evaluate the interrater reliability of the clinical spinal examination used in CPUP and scoliometer measurement in children with CP and we evaluate their validity compared to radiographic examination. METHODS: Twenty-eight children (6-16 years) with CP in Gross Motor Function Classification System levels II-V were included. Clinical spinal examinations and scoliometer measurements in sitting position were performed by three independent examiners. The results were compared to the Cobb angle as determined by radiographic measurement. Interrater reliability was calculated using weighted kappa. Concurrent validity was analyzed using the Cobb angle as gold standard. Sensitivity, specificity, area under receiver operating characteristic curves (AUC) and likelihood ratios (LR) were calculated. Cut-off values for scoliosis were set to ≥ 20° Cobb angle and ≥ 7° scoliometer angle. RESULTS: There was an excellent interrater reliability for both clinical examination (weighted kappa = 0.96) and scoliometer measurement (weighted kappa = 0.86). The clinical examination showed a sensitivity of 75 % (95 % CI: 19.4-99.4 %), specificity of 95.8 % (95 % CI: 78.9-99.9 %) and an AUC of 0.85 (95 % CI: 0.61-1.00). The positive LR was 18 and the negative LR was 0.3. The scoliometer measurement showed a sensitivity of 50 % (95 % CI: 6.8-93.2 %), specificity of 91.7 % (95 % CI: 73.0-99.0 %) and AUC of 0.71 (95 % CI: 0.42-0.99). The positive LR was 6 and the negative LR was 0.5. CONCLUSION: The psychometric evaluation of the clinical examination showed an excellent interrater reliability and a high concurrent validity compared to the Cobb angle. The findings should be interpreted cautiously until research with larger samples may further quantify the psychometric properties. Clinical spinal examinations seem appropriate as a screening tool to identify scoliosis in children with CP.

Scoliosis in a total population of children with cerebral palsy.

STUDY DESIGN: Epidemiological total population study based on a prospective follow-up cerebral palsy (CP) registry. OBJECTIVE: To describe the prevalence of scoliosis in a total population of children with CP, to analyze the relation between scoliosis, gross motor function, and CP subtype, and to describe the age at diagnosis of scoliosis. SUMMARY OF BACKGROUND DATA: Children with CP have an increased risk of developing scoliosis. The reported incidence varies, partly due to different definitions and study groups. Knowledge of the prevalence and characteristics of scoliosis in an unselected group of children with different CP types and levels of function is important for health care planning and for analyzing the risk in an individual child. METHODS: A total population of 666 children with CP, aged 4 to 18 years on January 1, 2008, followed with annual examinations in a health care program was analyzed. Gross Motor Function Classification System (GMFCS) level, CP subtype, age at clinical diagnosis of scoliosis, and the Cobb angle at the first radiographical examination were registered. RESULTS: Of the 666 children, 116 (17%) had mild and another 76 (11%) had moderate or severe scoliosis based on clinical examination. Radiographical examination showed a Cobb angle of more than 10° in 54 (8%) children and a Cobb angle of more than 20° in 45 (7%) children. The risk of developing scoliosis increased with GMFCS level and age. In most children, the scoliosis was diagnosed after 8 years of age. Children in GMFCS level IV or V had a 50% risk of having moderate or severe scoliosis by 18 years of age, whereas children in GMFCS level I or II had almost no risk. CONCLUSION: The incidence of scoliosis increased with GMFCS level and age. Observed variations related to CP subtype were confounded by the GMFCS, reflecting the different distribution of GMFCS levels in the subtypes. Follow-up programs for early detection of scoliosis should be based on the child's GMFCS level and age.

Windswept hip deformity in children with cerebral palsy.

Windswept hip deformity describes an abduction and external rotation position of one hip with the opposite hip in adduction and internal rotation. Windswept hip deformity may occur in association with hip dislocation and scoliosis. We analysed the prevalence of this deformity in a total population of children with cerebral palsy, and the impact of hip prevention and early treatment of contractures on the prevalence and severity of windswept hip deformity. The frequency of windswept hip deformity was 12% in the control group and 7% in the study group, comprising children in the hip prevention programme. The children with this deformity in the study group had a lower frequency of scoliosis and none had hip dislocation. It thus seems that the hip prevention programme results in a decrease in the number of children with windswept hip deformity, and a decrease in the severity of the deformity.