Posture and mobility of children with cerebral palsy

Background: Cerebral palsy (CP) is the most common cause of motor disability in childhood primarily affecting
posture and mobility. Secondary complications such as contractures and deformities may affect their seating or
lying posture, their ability to move around independently and cause pain. All of which can impact upon the child’s
ability to participate and engage in everyday activities and their quality of life.
Purpose: To increase knowledge of the prevalence and associations between postural asymmetries, scoliosis,
windswept hip deformity, contractures and pain of children with CP in supine and sitting; the time sequence and
incidence of scoliosis and windwept hip deformity and to identify risk factors preventing independent wheelchair
mobility.
Methods: All studies were based on data from the Swedish national registry and follow-up program for children
with CP at all levels of the Gross Motor Function Classification System (GMFCS) levels I-V. Study I-III were crosssectional studies. Study I examined wheelchair mobility in children aged 0-11 and analysed if reduced hand
function or range of motion were risk factors for not self-propelling or driving their wheelchair. Study II-III included
children 0-18 years, and Study II focused on postural asymmetries, postural ability and pain in children 0-18 years;
whilst Study III analysed associations between posture, deformities and contractures. Study IV was a longitudinal
cohort study of 4148 children followed until they developed either scoliosis or windwept hip deformity.
Results: Only 1 in 10 children self-propelled a manual wheelchair indepedently, whilst 3 in 4 children could
indepedently drive a power wheelchair. Poor hand function or gross motor function were the greatest risk factors
for being unable to self-propel or drive a wheelchair. Over half the children had postural asymmetries in sitting or
supine positions; 10.5% had scoliosis, 8.7% windswept hips, while 19.2% had knee contractures and 6.6% hip
flexion contractures. Postural asymmetries increased with age and GMFCS levels. An asymmetric posture
doubled the likelihood of pain; whilst severe postural asymmetries increased the likelihood of scoliosis (OR 9.1),
windswept hip deformity (OR 5.7-8.8), hip (OR 6.7) and knee flexion contractures (OR 12.2). Children unable to
maintain or change position were more likely to have postural asymmetries in supine (OR 2.6-7.8) or in sitting (OR
1.5-4.2). The likelihood of pain increased if the child had hip flexion contractures (OR 1.5) or windswept hip
deformity (OR 1.6). There was a higher incidence of windswept hip deformity (16.6%) than scoliosis (8.1%) as the
first deformity; windswept hip deformity developed first in more children at higher GMFCS levels, and with
dyskinetic (20.0%), or spastic CP (17.0%), whereas scoliosis developed in more children with GMFCS level V
(19.8%) or dyskinetic CP (17.9%).
Conclusion: Most children aged 0-11 years could not self-propel their manual wheelchair; whilst more children
could independently drive a power wheelchair. Power mobility should be considered earlier. Windswept hip
deformity presents earlier than scoliosis. Postural asymmetries are associated with inability to change position in
supine and sitting; pain; and with having scoliosis, windswept hip deformity, hip and knee flexion contractures. It is
important to reduce postural asymmet