Monday, September 24, 2012

Hip Subluxation and Cerebral Palsy

I have made a somewhat delibrate decision to stay away from potential "hot topic" discussions, however the issue of hip subluxation remains the top "talking point" in the overwhelming majority of the discussions I have with parents of children with Cerebral Palsy (CP). 

It is with this fact in mind that I will attempt to instill what I feel to be a fundamental understanding of the larger perspective of this greatly debated (and largely misunderstood) issue.  As always, the intention is simply to expand the panoramic and give some insight so that parents and extended families can more efficiently filter out the "noise" of information that floods their daily lives...and enable some clarity when making important decisions.

Diagnostics:  The very term "diagnosis" seems to somehow generate some relief and/or sense of progress...however, a diagnosis as such only serves to classify the particular symptomatic manifestations. The reality is that the challenge still exists.  With respect to hip subluxation, the actual "diagnosis" is unfortunately dependant on a relatively primitive device:  the x-ray.  Although the term "primitive" may be taken as somewhat controversial, it none-the-less reflects a very real and undeniable truth.  I will expand on my rationale in an effort to frame this particular philosophy with more clarity.

1)  X-Rays are 2-Dimensional
This is perhaps the most alarming reality to me...the fact that an assessment of a dynamic, 3-dimensional organism is being performed with a static, 2-dimensional image.  To be more precise, the human organism exists in 3-dimensional space and within a specific gravitational field.  Therefore, to look at it in 2-dimensional space with little or no gravitational forces placed on it seems somewhat primitive and certainly limits it's representation of the true reality.  

2) "Looking at the room through the keyhole"
I absolutely love this analogy...and for those who know me, you have heard me use it quite often.  The x-ray (in addition to the static / 2-dimensional limitations) is only representative of a very small area of the body.  This would be analogous to giving an estimate of a large conference room by looking through the keyhole of the door.  The unconscious assumption is that everything beyond the scope of the x-ray is fine...and in most cases, the pelvis (which is even INSIDE the x-ray image) is completely overlooked....and even worse, disregarded completely.  This is dangerously naive (if I may speak frankly) and further "waters down" the diagnostic reliability.

3) Bones and the diagnostic "monopoly".
The x-ray itself perpetuates the idea of the bones as the singular determinant of functional performance.  The reality is that without the soft-tissue contribution, the bones would simply clatter to the ground into a large pile of useless struts.  The human organism is a complex marvel of engineering that is charatcerized by biotensegrity.  Biotensegrity is essentially a term to describe the architecture of complex systems.  These systems are characteristed by BOTH tensional and compressional elements.  The bones are the compressional contribution to the system, while the soft tissue (muscles, tendons, connective tissue, fascia, etc...) contribute to the tensional component.  Therefore, given the obvious variables that contribute to functional performance, why have the bones been given such a diagnostic monopoly?  

Architectural Realities:
The reality with CP children (despite the diagnosis) is that they reliably demonstrate profound joint weakness.  Even in the mildest cases (Level 1 GMFCS), it is quite easy to demonstrate the significant soft-tissue / fascial weakness that exists.  The hypotonic individual demonstrates this in the most obvious way...however the spastic CP child can challenge this understanding.  The excessive muscular tension in essense "masks" the joint weakness behind an artificial shield of tight muscle.  However, in both cases there can be a reliable expectation of some level of joint weakness.  

Protocol / Procedural Flaws:
Given all of the realities mentioned above, perhaps the most glaring flaw is in the actual performance of the x-ray itself.  I am not making any direct comment on the people performing the x-rays, rather on the age-old paradigm of the "proper x-ray protocol" that has been formulated within a very narrow perspective and framework.  

The typical procedure plays out as follows...DESPITE the architectural / structural manifestations of the child, they are placed on their back, one person holds them down to the table with force from the top of the body to prevent any movement.  Then...another person actively grasps the ankles, PULLS the legs straight, TWISTS the legs into internal rotation, and holds them in place.  Although I was always aware of this protocol, it never actually "clicked" until I had an x-ray done on my 6 month old daughter.  Even in the case of a healthy child, the mere act of applying stress to forcibly move a child from their neutral position in an effort to acquire the "proper position" was (in all truth) absurd.  This was obviously uncomfortable and traumatic for such a young child, but when you compound the biomechanical distortions of a CP child into this framework...the result, at best, is highly unreliable.  

Fact #1:  The CP child demonstrates profound muscular imbalance, irregular muscle activation, and asymmetry...therefore the "straight" position is obviously one that is derived.

Fact #2:   A flat examination table is completely inadequate at enabling complete relaxation for a CPchild.  The proprioceptive feedback in a CP individual is significantly distorted, therefore a flat surface generates a great deal of sensory "confusion" and can, at times, trigger an exaggerated reaction.  Even in ourselves (healthy individuals), the first few seconds of lying on a flat surface requires some adjustment...imagine the challenegs within a CP child.

Fact #3:  This is perhaps the most important concept to remember and evaluate for yourself:  If all of the joints are weak...if one end of the body is being held down...and the other end is being held down at the ankles / lower leg...the only area available to manifest movement is the hip joint.  In other words, the inevitable muscular contraction and activation (whether it is voluntary or involuntary) will "exit" through the most proximal (closest) open chain...the hip joint.  Therefore, head of the femur will actively move within the acetabulum and, depending on when the image is actually taken, you may get vastly different images.

Final Question:
Although up until this point, I may be delivering a focused "condemnation" of the entire propcedure, but this would be a relatively narrow perspective.  I do not question whether they have a role in the effective and efficient formulation of competent diagniostics...I question the relative weight x-rays are assigned.  The implications of a "Hip Subluxation" diagnosis are enormous...therefore common sense only dictates that the diagnostic process by very exacting and comprehensive.  Therefore, the final question remains:  can the x-ray effectively confirm hip subluxation with an acceptable level of reliabilty?  The answer only comes through the prism of each specifc families value system...however, the above mentioned realities should have at least been given consideration.

The True "Subluxation" Test:
The relative implications of hip alignment become more prominent when there is significant amounts of load-bearing (weight-bearing) involved...therefore when children are non-weight bearing, then alignment can even be considered as secondary.  However, a very simple "litmus test" can be implemented when this issue is brought up:

1.   Is he/she in pain?
2.  Are they weight-bearing?
3.  Is the muscular mass within the leg decreasing?
4.  Is range of motion reduced/reducing?
5.  Is functional competence reducing?

If the answer to all of these questions is "NO"...then the subjective image of the x-ray is completely secondary.  The reality is that a hip that is subluxed will manifest in reduced range of motion, depletion of the muscular mass of the entire leg, reduced functional performance, and often times manifest pain or discomfort.  These are the real signs of a hip in a deteriorating condition. 

In all fairness, the x-ray can be included as a 6th consideration within the subluxation test simply because it can provide some useful information that contributes to the overall 3-dimensional reality...but as the only source of information from which potentially drastic decisions are made, it fails due to it's primitivity.

I hope this has been somewhat helpful and insightful...and more importantly, given some clarity to an already confusing situation.  I think it merits repeating that my true intention is merely to open different levels and perspectives...not to convince or persuade...rather to provide an amplified understanding so that the chosen path is determined with more conviction and confidence as well as with an overall sense of well-being.



  1. In a nutshell, you have described a "problem" and a view of subluxation that evades many peoples' understanding in the orthopedic community. For a number of our children, ortho's see a problem when there is no problem and cutting is there only solution which creates more problems. Thanks, best explanation I've read.

    1. Very well written and I love the manner in which you present very important detailed information on a very real situtation for many individuals and families within an enlightened context that was easily understood. It was a pleasure to read.

  2. Thank you for posting this! All of your research is very useful to the community! Would you be interested in writing a blog for our website? I know we are friends on facebook but I would love to have you write a blog as well.

    1. Most certainly! I had previously assumed that I responded to this message seems I am about 4 years late to the party! Please feel free to communicate with me at anytime here or my personal email:

  3. Gracias por poner otro punto de vista al tema que tememos muchas familias con niños con PC. Pero yo tengo una duda : ¿que hay que hacer cuando nos aseguran que la cadera ya está luxada? ¿Qué opciones hay?
    Gracias y un saludo.

    1. This is a tricky question...and therefore the reply is equally tricky. If I understand your question correctly, you are asking what options are there if you have been "assured" that the hip is "luxada". The most productive place to start this reply would be in reference to the post itself: The hip is in a deteriorating condition only when most of the criteria described are positive (pain/discomfort, reduced range of motion, reduction in the size of the upper leg, etc). If this is the case, then the particular options are numerous....which range from passive strengthening of the joint capsule to surgery. It is important to remember that the main message of this post is to highlight the fact that such a serious "diagnosis" such as subluxation is most often given far too early and without proper adequate evaluation...therefore when the situation actually gets to the point of TRUE subluxation, it is already progressed to a point where immediate intervention is needed. However, even if the x-ray seems to indicate some anomalies, if the true subluxation test criteria are not met, then the situation is less imperative...however it doesnt mean that it should be ignored "until it gets so bad that it warrants attention". Specific passive manual exercises are able to strengthen the joint capsule during this time, however describing them here would be extremely lengthy and drawn out. I am currently searching for ways to deliver this information, but havent found an effective mechanism to do so yet. However if you have other questions or require more enhancement, please feel free to post them here or on the facebook page. Cheers!

  4. hi gavin i have more or less the same questions i posted misha her x-rays on her facebook page so you can maybe look at them and give an opinion ,i did sent you an message to your facebook page ,thanks for all the usfull info always ,take care

  5. Absolutely brilliant Gavin. Once again you write about exactly what we've experienced. I've learned to take pillows or mats to soften the xray table, but to little avail as I still end up exerting massive pressure to achieve the position the team wants to see. One astute ortho doc noticed me folding my son like a Yogi (or a pretzel) to help reduce his dynamic tone for the physical exam, did a double take back to the xray, rechecked his range of motion and asked what happened during the xray process! He put a big note in the file to treat the images with caution because they don't tell the whole story. Otherwise, we'd have been in for surgery by now.

    1. Wow...great insight and personal experience! This is precisely the issue I was trying to project with thsi post! Thanks so much for sharing that couldnt have been more timely and appropriate! That Ortho should be applauded for his observation and common sense approach. Again, it is very refreshing to read this and to know that it has some definite relevance...many thanks!

  6. Bravo Gavin! This is an excellent post that I will be sharing!!!

    1. Thanks Jennifer! Im glad it was useful information...and yes, please do share!! Hope to see you all soon!