Efficacy of cervical orthoses in improving neck control of growing children with cerebral palsy

A narrative review

Abstract

The purpose of this study was to perform a literature review evaluating the efficacy of cervical orthosis in maintaining correct head posture and neck control in children with cerebral palsy (CP). A literature search has been conducted using the following word or phrases: CP in children, head support, neck control, and orthosis. Database search included PubMed, CINAHL, O and P Library, ScienceDirect, and Google Scholar. Only four literatures met our search criteria indicating very limited evidence in this area, with only one relevant literature in the last 5 years. Almost all studies advocate the beneficial effect of orthosis in maintaining correct head posture and improved neck control, but number of studies and level of evidence are insufficient. Furthermore, there are very limited recent literatures available, and future studies are required with appropriate orthotic devices and strong research design.

INTRODUCTION

Cerebral palsy (CP) is a very common motor disorder occurring due to abnormal brain development in children.[¹] It is characterized by loss of selective motor control, abnormal muscle tone, agonist and antagonist muscle imbalance across the joints, weakness, and compromised equilibrium reactions.[²] It represents a diversified set of clinical ailment, which describes the static disorders of posture and movements. The movement disorder may increase with growth of a CP child, if remain untreated. The motor disturbance in CP is mostly accompanied by trouble in sensation, perception, communication and conduct, epilepsy, and secondary musculoskeletal issues.[³] Studies from various countries quote a prevalence of 2 per 1000 childbirth[¹] which is about 2.95/1000 childbirth in India.[⁴] This indicates a relatively higher prevalence of children with CP among Indian population. Lack of postural control in children with CP is the major hallmark of disability.[⁵] The stabilization of head in space is one of the first primary goals of postural control in such children as the organs of visual and vestibular systems are embedded in the head, which is critically important for balance and coordination. Impaired neck control has been most often quoted as an early threat for delayed development of a child in future and also represents as a marker in predicting whether the child will be diagnosed with CP by 2 years of age.[⁶] Poor neck control not only troubles in overall control and coordination of body and posture but also affects the feeding process of a child and unusual salivary discharge. There are many treatment strategies to achieve improvement in neck control in children with CP. These include exercises, stimulation, neurodevelopmental therapy, various orthoses, pharmacological managements, injection, and surgical procedures. The efficacy of cervical orthosis in improving head control of such infants is not well stated. There are very limited evidence of orthosis for head support or neck control used primarily as temporary supplemental aid in posture and gait for children with CP.[⁷⁸] This literature review focuses on gathering evidences regarding available orthotic interventions for improvement in neck/head control in children with CP and also to find their efficacy.

METHODOLOGY

A literature search has been conducted in four databases, namely PubMed, CINAHL, O and P Library, ScienceDirect, and Google Scholar. There has been no search time frame as very limited relevant studies were available. Early work was included due to insufficient modern approaches and technologies that are relevant today. The following keywords were included in the search: Cerebral Palsy in children, head support, neck control, and orthosis. The articles addressing the efficacy of various orthoses in head posture and neck control among growing children with CP were considered only. The studies revealing the effectiveness of orthosis in maintaining head posture other than CP (as in SCI or other neuro-musculo-skeletal problems) have been excluded. All publications in English have been considered [Figure 1].

Figure 1: Process of selection of literature

RESULTS

During electronic search, we got total 4403 articles, out of which only 4 met our search criteria. We find only one literature in the last 5 years, and the remaining three were very old and published during 1960–1980. All these articles discuss the effect of various orthotic designs on head posture, active neck control, and head orientation in children with CP of various age groups. Almost all the studies reveal that the orthosis used in a CP child has improved the head posture while sitting, voluntary neck control on stimulus, and head orientation in space while activities. The level of evidence for the two out of four studies were III and the remaining two were V [Table 1] as per level of evidence classification system.[⁹]

Table 1: Level of evidence for the relevant literatures^[9]

DISCUSSION

The maintenance of correct head posture is an activity which can be learned by many children who have assumed an abnormal head posture due to central nervous system dysfunction. This can be achieved by appropriate diagnosis and treatment strategy. Helen J Mayes in 1961 designed a head support primarily as a temporary supplemental aid in posture during gait training with walker and can also be attached with tricycle. The author claims its effectiveness on patients with CP whose head is not held erect because of lack of control rather than weakness, but the statement lacks the supporting factual data. Halpern et al. in 1970 investigated a group of 14 CP children (3–12 years of age), with poor head posture and neck control during a prolonged therapeutic program which includes a variety of stimulation techniques as well as various kinds of orthotic devices: a padded sheet metal collar with chin rest, a modified Boldrey brace, a stocking cap head support suspended by a spring from an overhead support, and a hinged head halter. The posture and orientation of head has been improved with the use of dynamic head suspension in most of the children. Mital et al. in 1976 used Milwaukee brace in nine CP patients (6 – male and 3 – female) having problem with head, neck, and trunk control. Eight of them were suffering from quadriplegia with athetosis and the remaining one has spastic quadriplegia. After an initial period of apprehension, the brace has added greatly to the quality of life within the limits of the patients' abilities. Follow-up has ranged from 3 months to 5 years (mean 3½ years), and no deleterious effects have been noted.

Brown et al. in 2018 determined the efficacy of headpod used to improve head control in 14 children with CP classified as Gross Motor Function Classification System (GMFCS) level V. Head control without device (baseline) has been measured by active time a child could hold the head upright and number of head bobs in 5 min. While using headpod regularly for six months (45 min per day), there was a significant increase in duration of active head control in the children with Cerebral Palsy. The average head bobs has been also decreased simultaneously.

The feasibility of orthosis in improvement of head posture and neck control in children with CP is not well understood due to the lack of relevant studies in this prospective. In the current literature review, we found only four studies [Table 2] endorsing the effectiveness of such device in children with CP. The head support described in the study by Mayes in 1961 includes only the design description and lacks clinical trial and supporting data. Likewise, the study on Milwaukee brace to maintain head posture in children with CP reported by Mital et al. in 1976 also lacks appropriate justification on experimental ground. Furthermore, their findings differ from other authors (Hoffer et al. 1974) at that time. The study performed by Brown et al. and Halpern et al. presents some stronger evidence on experimental ground. Although the role of orthosis in improving head posture and neck control is not well clear due to lack of quality literatures, erect head is the primary requirement to improve function and neurodevelopmental impairments.

Table 2: Study, methodology, and conclusion

CONCLUSION

The result of the study reviewed suggests the beneficial effect of cervical orthosis (preferably dynamic designs) for active neck control and improved head posture on children with CP. However, the quality of methods for two out of four studies were inappropriate. The remaining two studies somehow present strong clinical analysis; future studies are required with more innovative orthotic design and randomized control trials.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.