determinants of hip pain eric boldingh oct 2014
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determinants of hip pain in adults with severe cerebral palsyTRANSCRIPT
8 april 2023
Determinants of hip pain in adult patients with severecerebral palsy
Eric Boldingh, MD (1951)Rehabilitation specialist for severe handicapped children
Eric Boldingh determinants of hip pain in adult patients with severe CP2
Research
160 adults (16-84 yrs) with CP, GMFCS V Mainly living in residential setting
Assessing
X ray of the pelvis
•Pain•Fractures•Decubitus ulcers •Seating problems•Handling problems /
contractures
Independent variables
Dependent variables
Eric Boldingh determinants of hip pain in adult patients with severe CP3
Migrationpercentage (MP)
Instruments – X ray pelvisInstruments – X ray pelvis
Arthrosis: Tönnis classificationScale of 4
Instruments – X ray pelvis – deformity of femoral head
None
Moderate
Severe
Eric Boldingh determinants of hip pain in adult patients with severe CP5
Pain instrument Pain instrument Faces Pain Scale
Developed for children from the age of 4 Suitable for
developmental age of 4 or more for non-speaking patients people able to use scanning
Preselection: Columbia Mental Maturity ScalePreselection: Columbia Mental Maturity Scale
Assessing level of development and ability to discriminate drawings and indicate a choice Question: which drawing does not match? 25 answers correct: developmental age ≥ 4
Drawings daily situationsDrawings daily situations
Painful situations (6)
(e.g. sting of wasp)
Non-painful situations (6) (e.g. eating bread)
Drawings daily situationsDrawings daily situations
Situation possibly painful in subluxation of the hip (6)
Locate pain on drawing human figureLocate pain on drawing human figure
Eric Boldingh determinants of hip pain in adult patients with severe CP11
Results
30 out of 160 patients have pain in the hip region according our criteria (=18%)
Two groups can be distinguished: 1. With migration measurable: <100% or
total luxation (n= 140). 2. With migration immeasurable due to
special relation femur / pelvis (n=20).
Eric Boldingh determinants of hip pain in adult patients with severe CP12
Group 2, n=20
In group 2 patients have a special relation between femur and pelvis. These are Resection of the femoral head
Distal or proximal Ankylosis Aberrant contact of femur and pelvis
This occurs mainly after – failed - surgery
Eric Boldingh determinants of hip pain in adult patients with severe CP13
Eric Boldingh determinants of hip pain in adult patients with severe CP14
Determinants of pain: relationship between situation of the femoral head and pain
Migration of femoral head N With pain
Group
I <30% 89 8 (9%)
II 30-59% 35 5 (14%)
III 60-89% 9 2 (22%)
IV >90% 7 3 (42%)
V Abnormal configuration 20 12(60%)
Total 160 30(19%)
Spearman’s Rho = 0.37; p = 0.000
Eric Boldingh determinants of hip pain in adult patients with severe CP15
Pain per categoryP ai n per c entage per mi gr ati on c ategor y
0%
20%
40%
60%
80%
100%
Categor y
P ain-
P ain+
P ain- 88 24 6 4 2 2 3 1
P ain+ 9 5 1 3 1 2 5 4
MP < 33%MP 34-
66%
MP 67-
99%
MP >1 00,
head
Distal
r esectionAnkylosis
Aber r ant
contact
P r ox
r esection
Eric Boldingh determinants of hip pain in adult patients with severe CP16
Relation between migration and deformity of the femoral head
Deformity of femoral head Total
None Moderate Severe
Migration < 30% 32 46 11 89
30-59% 8 9 18 35
60-89% 3 6 9
>90% 1 6 7
Total 41 58 41 140
Spearman’s Rho = 0.46; p = 0.000
Crude and adjusteda odds ratios (OR) and 95% confidence intervals (CI) for determinants of hip pain, groups I-IV, n=140
n=140 crude OR adjusted ORa
Migration/deformity
migration < 33% and no/moderate deformity 1.00 (ref) 1.00 (ref)
migration 33% and/or severe deformity 2.79 [1.01 - 7.70] * 1.70 [0.39 - 7.34]
Osteoarthritis
none 1.00 (ref) b 1.00 (ref) b
mild 1.31 [0.42 - 4.04] 1.29 [0.40 - 4.15]
moderate 0.85 [0.09 - 7.85] 0.54 [0.05 - 5.62]
severe 2.83 [0.60 - 13.44] 1.60 [0.28 - 9.12]
Asymmetry of migration
none 1.00 (ref) c 1.00 (ref) b
mild 1.33 [0.36 - 4.86] 1.19 [0.30 - 4.81]
moderate 2.20 [0.51 - 9.57] 1.45 [0.23 - 9.03]
severe 8.23 [1.79 - 37.87] * 5.43 [0.82 - 35.8]
* p<0.05; a adjusted for the other variables in the table; b p for trend not significant; c p for trend 0.011
Eric Boldingh determinants of hip pain in adult patients with severe CP18
Patients with abnormal configuration of femoral head and pelvis (group V; n= 20)
Situation Number History of bone surgery
Pain as indication bone surgery
Hip pain
After proximal resection of the femoral head (subcapital) 5 5 4 4
After distal resection of the femoral head (level minor trochanter) 3 3 2 1
Ankylosis of femur and pelvis 4 4 2 2
Aberrant contact between (rest of) femur and pelvis 8 5 5 5
Total 20 17 13 12
Eric Boldingh determinants of hip pain in adult patients with severe CP19
Conclusions
Migration of the femoral head is closely related to deformity.
Pain in patients with severe cerebral palsy is related to migration of the femoral head deformity of the femoral head asymmetry of migration of the femoral head
Failure of bony surgery is strongly associated to pain
Eric Boldingh determinants of hip pain in adult patients with severe CP20
Recommendations (decision tree on poster) Migration / deformity of the femoral head should be
prevented With soft tissue surgery (literature) Before the age of 5 (literature)
Prevention or treatment by bony surgery is disputable because of the great impact on the patient in this group
A distal resection of the femoral head will cure the pain (this research and literature).
Eric Boldingh determinants of hip pain in adult patients with severe CP21
In cooperation with
Monique A. M. Jacobs-van der Bruggenb, Cees F. A. Bosc, Gustaaf J. Lankhorstd,e,and Lex M. Boutere
b National Institute of Public Health and the Environment (RIVM), Bilthoven,
c Juliana Children's Hospital, Den Haag, d Department of Rehabilitation Medicine, and
e Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands.
