"HIP BRACE" promises delayed hip surgery and improved life quality in cerebral palsy patients: JAMA

SOUTH KOREA: An original investigation published in JAMA under Physical Medicine and Rehabilitation outlined the promising role of a novel hip brace in delaying hip surgery by preventing the progression of hip displacement. The investigation revealed how the life quality of cerebral palsy patients (nonambulatory) could be improved with this approach.

Children suffering from cerebral palsy manifest with musculoskeletal deformities, among which progressive hip displacement is the most common. This deformity is painful and is associated with pelvic obliquity and scoliosis. The quality of the patient's life is adversely affected due to the inability to sit, stand, and walk, with difficulties in the basic routine activities like dressing, bathing, and perineal care.

Many hip surveillance programs have been established with the aim of disc displacement prevention, identification, and management.

There is a need to prevent complex salvage surgery. The conservative approach remains conflicting, while an effective treatment strategy primarily focuses on surgery.

Nonsurgical treatment modalities for hip displacement, like abduction braces, seating systems, and botulinum injections, have shown inconsistent results. Previously researchers have explained how seating systems with medial knee support behave as a fulcrum. Dynamic hip compression bandages have proved to have the potential for protective benefits.

Considering the above facts and figures, the researchers of the present study built a hypothesis stating hip brace aids in stabilizing the hip joints, which reduces hip adductor activation and provides a protective function.

The team led by Dr. Kim and Dr. Yoon from the Department of Physical Medicine and Rehabilitation at Anam Hospital and Pusan National University Hospital, Biomedical Research Institute of Pusan National University School of Medicine, Busan, South Korea, aimed to investigate "How does a newly designed hip brace prevent progressive hip displacement in children with nonambulatory cerebral palsy?"

The research points from the study are:

• The trial was conducted at four tertiary hospitals in South Korea ( July 2019 -November 2021).

• The study participants had a history of cerebral palsy, aged one to ten years, with GMFCS levels IV or V and quadriplegia or diplegia.

• Written consent was obtained from the child and caregiver.

• A total of 66 patients were included in the study.

• The mean age of 33 patients in the intervention group were 68.7 months, with 75.8% boys.

• The 33 patients in the control group had a mean age of 60.7 months, with 60.6 % boys.

• Hip brace was worn for at least 12 hours/ day in the intervention group.

• The study measured primary and secondary outcome, which was MI (Reimers migration index) at 12 months and MI at six months, hip ROM, Cobb angle, pain intensity, patient QOL, satisfaction scores, respectively.

• A visual analog scale measured pain intensity.

• The changes in quality of life was measured by the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD)

• A Likert scale measured satisfaction scores for the hip brace in the range of 1-5.

• The baseline mean MI in the intervention and control groups was 37.4% and 30.6%, respectively.

• The mean difference between the intervention group and control group of MI at 6 and 12 months was −8.7 and −12.7 percentage points.

• The favorable changes were recorded in CPCHILD of the study group, most significant at the 6-month follow-up than the control group.

• Reimers migration index decreased significantly at 12-month follow-ups in the group wearing hip brace than the control group.

Dr. Han from the Research Institute of Human Ecology at Chungbuk National University said, "Our study highlighted the most important insight on the newly developed hip brace. To prevent hip displacement, this is a good option for nonsurgical treatment in children with nonambulatory cerebral palsy." They wrote, "The quality of life of such patient could be improved with novel hip brace approach, and it is promising in treatment goals."

The results of our study are meaningful. This is an excellent approach to delay surgery, they said.

The researchers explained that a hip brace was developed for analysis. South Korean Ministry of Food and Drug Safety approved it as a Class 1 medical device. The brace comprises inner pants and outer fabric bands (upper, lower, and thigh straps). The upper straps protected hip joints from displacement while the lower prevented coxa valga. The thigh straps prevented hip adduction and helped with alignment.

A hip abduction brace and botulinum toxin injection combo has been ineffective in hip displacement prevention. These results presented in the study are indicated with beneficial effects. This is because previous studies have had unverified results and erroneous conclusions owing only to the ineffectiveness.

Theoretically, weight-bearing exercises can be applied in a standing position so that hip abductors are activated and the acetabulum is stimulated. To control adductor spasticity, they mentioned we can use botulinum toxin injection at the adductors or adductor tenotomy.

Some of the mentioned study limitations are higher dropout rates, difficulties in patient enrollment and follow-up, hip ROM and pain change were insignificant, etc. Our study did not measure the actual wearing time of the braces though the real time was 12 hours/ day, so this was a limitation of the study, they wrote.

This research was supported by grant from the Korea Health Technology R&D Project and was funded by the Ministry of Health & Welfare, Republic of Korea.

Further investigations with long term Follow-ups are warranted.

Further reading:

Kim BR, Yoon JA, Han HJ, et al. Efficacy of a Hip Brace for Hip Displacement in Children With Cerebral Palsy: A Randomized Clinical Trial. JAMA Netw Open. 2022;5(11):e2240383. doi:10.1001/jamanetworkopen.2022.40383