This presentation, as part of the Pediatric Rehabilitation Focus Review, will cover comorbidities in CP. I have nothing to disclose. Cerebral palsy is defined by much et al. as an umbrella term covering a group of non-progressive but often changing motor impairment syndromes secondary to lesions or anomalies of the brain arising in early stages of its development. From 2004 to 2006, an international working group developed a consensus clinical definition for CP, a group of permanent disorders of the development of movement and posture causing activity limitation that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior by epilepsy and by secondary musculoskeletal disorders. Most children with CP have at least one other of these comorbidities. Unstable medical issues can have profound effects on children, their growth and development, their ability to participate in school and therapies, and may cause family stress as well. It is well documented that negative health changes such as constipation or uncontrolled seizures can also lead to worsening of spasticity. Knowledge of and appropriate management of these comorbidities facilitates the overall health and well-being of these children. For the purposes of this talk, we'll divide these conditions into three main groups. Positive emotional and behavioral, medical, and orthopedic. Spasticity management and movement disorders will be reviewed in a separate talk. The disorders covered in this section will include intellectual disability, emotional behavioral concerns, sensory impairments, pain, and disordered sleep. While not part of the definition of CP, intellectual disability is fairly common. As we will discuss with many of these comorbidities, the greater the motor impairment and more likely the greater the brain injury or abnormality, the higher the risk of other issues. This is the case in cognitive function, noting that a significant proportion of those with CP have lower IQ and an even larger proportion have been noted to have mild learning issues, including attention and executive function disabilities. Parietal occipital periventricular hemorrhage, intraventricular hemorrhage, ventricular dilation, white matter reduction, and bilateral injury were associated with greater executive functioning impairment, though there is limited research on the correlation with imaging. Often there is a discrepancy in verbal and performance IQ, with higher verbal scores for diplegic patients. In the converse, those with focal lesions, such as those with athetoid CP due to basal ganglia lesions, are more likely to have normal intelligence. Neuropsychology and other cognitive or screening tests are recommended, however there are difficulties in testing and scoring for those with dysarthria or communication difficulties requiring device use or other methods, visual impairment, upper extremity motor impairment, which may manifest as underestimation of intelligence with a difference in expressive language, difficulties with hand-eye coordination, or visual upper extremity impairment. There is a wide prevalence of mood and behavior issues, but they are not always well defined in the literature, with studies noting anywhere from 25 to 80% prevalence. Physical and behavioral problems seen in CP include attention deficit disorder, passivity, immaturity, anger, sadness, impulsivity, emotional lability, low self-esteem, and anxiety. Even children with mild motor impairment, those in GMFCS motor function class 1, had fewer peer interactions and reciprocated friendships than peers without CP. There is limited research on effective interventions. Interventions in cognitive behavioral therapies may be beneficial. Awareness is extremely important, and referral to local mental health specialists is recommended for concerns. Children with cerebral palsy frequently have deficits in proprioception, stereognosis, and are commonly bilateral, even in hemiplegics, not following the motor impairment pattern. These deficits are generally not as well understood as the motor issues. Pain is also a common concern in the CP population. It is correlated with higher motor involvement in female gender, as well as in more ambulatory patients. Evaluation of pain and irritability complaints is more difficult in the nonverbal and significantly cognitively delayed child. Common signs in nonverbal children may include vocalizations, facial expressions, vital sign changes, sleep changes, or changes in tone or movement. Thorough history and evaluation must be done to ascertain any focal areas of discomfort. Children with CP are at risk for the same common medical issues as their peers, including ear infections, dental caries, urinary tract infections, as well as being higher risk for other common issues, such as gastroesophageal reflux, constipation, and more. Common pain-causing issues include those from the GI system, gastroesophageal reflux and constipation, and the neuromuscular system, involving spasticity or spasms, hip dislocation, or fractures. Other occult injuries may include skin breakdown, ocular or dental injury, and occult infections such as UTI or osteomyelitis. In addition, medically complex children may have other types of chronic pain, such as neuropathic pain or autonomic dysfunction, that also must be assessed and addressed. Sleep difficulties and disorders occur in about 25% of typically developing children and have been noted in up to 80% of those with neurodevelopmental disorders. Sleep issues are likely multifactorial, usually a combination of intrinsic issues such as visual impairment, seizures, and altered circadian rhythms, and extrinsic factors, including the physical and social environments. Sleep problems are issues for both the child and the family, as they interfere with the household function. It has been shown that rates of parental depression, anxiety, and fatigue, as well as family satisfaction and happiness are lower in a home where a child has sleep issues. The child him or herself is at risk for daytime sleepiness, behavior and academic difficulties, and mood disorders. Assessment for underlying medical issues such as central or obstructive sleep apnea, reflux or feeding issues, spasticity, and pain should be evaluated and addressed as appropriate. Behavioral sleep recommendations should be discussed with families, including sleep routines, a quiet, dark sleep space, and can be helpful to review along with counseling for appropriate behavioral interventions. There are no FDA-approved medications for sleep disorders in children, however, several medications are commonly used in the neurodevelopmental disability population. These include melatonin, clonidine, trazodone, and amitriptyline. Many of these have limitations, including daytime sleepiness and other side effects, including the risk of lowering the seizure threshold. The section on medical comorbidities in CP will review the following, including seizures, GI issues, respiratory issues, vision and hearing impairment, drooling, and bone health. Seizures have been categorized as generalized, which includes tonic-clonic, absence, myoclonic, atonic, and more, focal, and an unknown category, which includes infantile spasms and Lennox-Gastaut syndrome, which is common in patients with more involved cerebral palsy. The rate of epilepsy also varies as a function of the amount of brain injury involved. Seizures are more prevalent in quadriplegic and hemiplegic CP than in diaplegic or extrapyramidal CP, though the literature does vary. A study by Delgado et al, looking at CP and seizure type, noted about 70% of those with CP and epilepsy experienced focal seizures, while 30% experienced generalized. Treatment of seizures often includes anti-epileptic medications to reduce neuronal excitability. The goal is elimination or reduction of seizure activity with, without, or with limited side effects. More recently developed medications, such as levotiracetam and oxcarbazepine, are generally better tolerated with fewer side effects than first generation anti-epileptics, such as phenobarbital. Side effects may include sedation. Though most children tolerate low to moderate doses of one medication, the risk of clinically significant side effects increases with use of multiple medications. Diet therapy is another option for difficult to manage seizures. Use of a high-fat, low-carb diet has been shown to reduce seizures by up to 50%. Use of the ketogenic diet requires careful monitoring of glucose intake and ketones and may have adverse effects on bone health and growth. Less restrictive diets, such as the modified Atkins or low glycemic index diet, have shown promise with improved compliance. Surgical interventions, such as placement of a vagal nerve stimulator or surgical resection, are considered for those with seizures refractory to medical intervention. Gastrointestinal issues are extremely common in children with CP, noting a prevalence up to 92%. Reflux, slowed motility, and constipation are very common in this population. Cerebral palsy motor disabilities may be associated with oromotor impairments as well. Poor or weak suck, retained reflexes such as tongue thrust, poor oral and pharyngeal coordination, as well as spasticity and tonic bite reflexes can contribute to difficult and unsafe oral feeding and digestion. In general, the more severe the motor involvement, the more likely and severe the feeding difficulties. Studies have noted significantly more issues in those with GMFC at levels five than in even level four. Impairments in oromotor function and coordination increase risk for aspiration and require diligent monitoring and assessment. Children with CP have a high degree of variability in calorie intake and calorie needs. Some have requirements more than others, some have requirements much lower than age-based norms, others have much higher. Measurements need to be monitored carefully, though it is difficult to obtain reliable ones in some populations due to contractures or mobility difficulties. It's recommended to try to monitor weights and heights the same way each time, such as in or out of the wheelchair, with or without a parent, and on the same scale if possible, as well as trying to use the same length measurements, whether they be segmental or stretched measurements. Other measurements that may be helpful to assess nutrition include arm circumference and fat or skin fold measurements. Micronutrient deficiencies are also common, including calcium and vitamin D, which will be discussed more in the bone health section. Specialized growth charts exist for children with CP, grouping them by gender and GMFCS levels. As can be seen here, there are significant differences in those with higher GMFCS levels in comparison to their peers, though even children at GMFCS level one often do not follow the typical curves. These charts are generally best used in conjunction with the WHO or CDC standard charts and a good nutritional evaluation. The factors affecting growth are usually multifactorial. Inadequate intake is often present and related to oropharyngeal dysfunction, limiting a child's intake, and can also be related to fatigue with feeding, poor positioning and tone, or food preferences or allergies. It has been shown that children with need for even minor diet modifications have lower fat stores than their peers. Children may also experience increased calorie loss through GI issues such as GERD or absorption issues. They may also require increased calories to keep up with spastic muscles or dystonic movements or may require fewer calories due to limited mobility. Up to 75 percent of patients with CP have reflux that persists outside of the common infant period. Factors influencing reflux include central nervous system disturbances, supine positioning, and limited mobility, and the use of tube or liquid feedings. Slow motility and delayed emptying occurs in up to two-thirds of patients with CP, though its relationship to GERD is unclear. Management options are many, beginning with conservative treatments such as positioning or adjustment of feeds. Medication options include PPIs, proton pump inhibitors, and H2 blockers, as well as motility agents if appropriate. Children with more severe reflux may benefit from more invasive and intensive options such as a Nissen fund application or post-pyloric feeds. Constipation is also very common and present in up to 90 percent of CP patients. This is likely due to limited or slowed motility and decreased mobility and movement. Treatment options include diet modifications such as increased fluids and fiber, though studies do show limited effectiveness with this, medications including stool softeners, osmotic agents, motility agents, or evacuants such as suppositories or enemas if needed. Rare cases that do not respond well to the above may be managed with surgical interventions such as the anterograde enema procedure. Children with CP have increased risk of pulmonary infection and disease compared to peers. With their underlying brain injury and muscle weakness and tone abnormalities, they often have ineffective cough, poor swallowing, and airway protective mechanisms putting them at risk for aspiration, as well as a higher likelihood of other contributing conditions such as GERD and seizures. Aspiration remains a significant issue for many patients related to poor oropharyngeal management of liquid and solid. Management of oral intake, at times with strictly tube feedings, and management of GERD and sialorrhea can decrease the risks. Children with CP are also at risk for both central and obstructive sleep apnea, often worsened by other respiratory conditions, as well as abnormal tone and scoliosis or contractures. Patients may be managed with positioning or may require positive pressure ventilation or tracheostomy. One of the most common issues is noisy breathing related to anatomical abnormalities or medical conditions such as reflux. Airway hyposensitivity and ineffective cough can lead to poor airway clearance, pneumonia, atelectasis. Premature infants are at higher risk for bronchopulmonary dysplasia and chronic lung disease. Children with CP are at risk for the same common childhood conditions as their peers as well, including asthma and other atopic diseases. Visual impairment is noted to be present in 10 to nearly 100 percent of children with CP in various studies. Strabismus is the most commonly reported disorder, but refractive errors, abnormal saccades, and reduced visual acuity have been noted in diplegia and less frequently in those with hemiplegia. The visual issues of those with less involved CP tend to mirror common issues in the general pediatric population, while children with the highest motor involvement have the highest risk for high myopia, lack of binocular fusion, dyskinetic strabismus, severe gaze dysfunction, and optic neuropathy or cortical visual impairment. Early assessment and treatment is vital for development and quality of life. Hearing impairment is felt to be present in anywhere from 4 to 13 percent, with severe hearing loss noted in anywhere from 2 to 12 percent. The proportion of severe hearing loss seems likely related to an increased survival of extremely premature infants. This is often associated with congenital torch infections, bacterial meningitis, hypoxia, and ototoxic medications. Again, early evaluation and treatment is important for communication and language development. Sialorrhea is defined as increased loss of saliva in children over the age of three to four years. It occurs in approximately 40 percent of patients with CP and is generally related to limited or a motor control and not increased saliva production, though saliva volume may be affected by reflux or medication. Spillage of saliva can occur out of the mouth or anteriorly, resulting in skin, hygiene, and a variety of psychosocial problems and concerns, or it may spill posteriorly into the pharynx and result in chronic aspiration. Patients may have one or both types of drooling. Non-medication treatment options for sialorrhea may include oral motor, sensory, and behavioral therapies, or various oral appliances. There's limited evidence for all of these, however they are generally low risk and worth discussion or trial at family's interest. Sialorrhea may also be effectively treated with anticholinergic medications such as glycopyrrolate and scopolamine. These medications are generally well tolerated, though sometimes limited by side effects such as dry mouth and constipation. Additional treatment options include botulinum toxin injections to the salivary gland, or various surgeries if necessary, such as ligation of salivary ducts or removal of parts of salivary glands. Bone health in patients with CP is an important issue. Risk factors for poor bone health include poor nutrition and absorption issues, decreased exposure to sunlight, decreased weight bearing and activity level, and use of certain medications, most commonly anti-epileptic medications and proton pump inhibitors. In children with CP, low bone mineral density occurs because of decreased accrual of bone versus the loss of bone seen in older adults. Low bone mineral density can lead to increased risk of fractures. Osteoporosis in children is defined as both low bone mineral density and a significant history of fracture. Bone mineral density is determined by DEXA scan. For children, a z-score is reported and compared to reference data of age and gender matched children. The distal femur is a preferred site in patients with CP because they often have hip abnormalities. The scores are reported as a standard deviation from average, with a score of less than minus two significant for low bone mineral density. Scans may be limited by hardware. Prevalence of fractures is estimated to be about 20 percent of non-ambulatory children and young adults with CP, with an incidence of 7 to 9.7 percent per year for those with severe CP. When fractures occur, there's usually minimal trauma involved and the distal femur is one of the most common bone sites affected. There are several prevention and assessment strategies recommended for bone health in CP. Nutrition remains a mainstay. It is recommended to monitor growth and diet to ensure proper nutrition and calcium and phosphorus intake. Vitamin D is frequently low in the population as a whole and supplementation is safe. Serum levels should be monitored annually. Increased weight bearing may involve specific exercises or activities, use of standing or walking equipment, or low amplitude mechanical loading. If an individual CP has a fragility fracture, additional evaluation should include blood work, x-rays, and a DEXA scan to assess bone density. In addition to optimizing nutrition, vitamin D, and calcium levels, treatments with bisphosphonates can be considered. The systematic review published by Fellings et al. resulted in development of a clinical practice guideline, which may be accessed at the website listed on the slide. Question. The optimal use of DEXA scanning to evaluate for osteoporosis in CP involves, A, scanning of the hip or lumbar spine, B, avoiding scan in the area of fracture, C, definition of low bone density as a z-score less than minus 2.0 standard deviations compared to reference norms, or D, definition of low bone density as t-score less than minus 2.5 standard deviations compared to reference norms. The answer is C, definition of low bone density as z-score less than minus 2.0 standard deviations compared to reference norms. For children, a z-score versus t-score in adults is reported and compared to a reference data adjusted for the child's age, sex, and height. In children, the definition of low bone density is a z-score less than minus 2.0. The distal femur is preferred for scanning because children with CP often have hip problems such as contractures, deformity, and prior surgery or hardware. Although the distal femur is the most common site of fracture, plenty radiographs of the fracture site are recommended for osteoporosis evaluation. This section will discuss orthopedic comorbidities in CP. Musculoskeletal problems are nearly universal in cerebral palsy, related to abnormal muscle tone and movement disorders, as well as motor delays or abnormalities and other medical comorbidities. Common issues noted include hip problems such as dysplasia, subluxation, and dislocation, gait abnormalities and pain, joint contractures, and neuromuscular scoliosis. Monitoring is an important part of CP care. Hip x-ray monitoring generally starts by age 2. Spine films are obtained when concerns for scoliosis arise. Indications for surgery include the two basic tenets of improving static problems as well as dynamic problems. Static problems reduce subluxated or dislocated joints, correct bony abnormalities or rotational issues, fuse joints to improve stability, or excise excess or heterotopic bone. Dynamic corrections may include tendon or intramuscular lengthenings, muscle releases, transfers, or neurectomies. As with all of our medical planning, it is important to keep the goals in mind. Discussions with families should include surgical recommendations and expected recovery, as well as any possible or expected complications and outcome goals. Are we correcting a current issue with gait or hygiene, working to prevent arthritis or joint disfigurement, improving pain or lifting a limb, or improving mobility, or improving mobility and mobility It's important to discuss issues such as the extent that this will improve ambulation or function, the ability to continue to assist with transfers, or hygiene or other family expectations. As Mercer ranks as, the decision is more important than the incision. Pre-operative decision making is the number one determinant of surgical outcome. It is very important to make sure that our medically complex children have an appropriate nutritional assessment, the correct radiographic assessment for surgical planning, and gait analysis. It's been shown that pre-op gait analysis delays and or reduces surgery burden with the same or improved outcomes. Surgical timing is an important part of the decision making process. Recommendations are to try to delay bony surgery, especially hip reconstruction, until age 7 to 10 if possible. Patients are monitored and generally interventions occur after they've reached a plateau in function or are unable to be appropriately managed with other spasticity interventions or other levels of care. Semels or single event multi-level surgery is the standard of care. Semels involves, obvious as the name implies, multiple surgeries done in one surgical encounter. Birthday cake syndrome is what previously happened in which patients would have small numbers of intervention done nearly every year, resulting in a constant cycle of surgery and recovery. This chart shows common interventions in cerebral palsy for spasticity and orthopedic management and the common ages in which they occur. As previously mentioned, soft tissue surgeries are used to improve dynamic or muscular problems. Soft tissue surgeries are surgical procedures done on muscles and tendons with the goal of improving range of motion, release of contractures, and balancing forces across a joint with an end goal of improving function and quality of life. The procedures tend to be less involved than bony interventions and require less recovery and rehab time. Key areas that these interventions are often performed include wrist, elbow, and finger flexors, as well as the hip adductor, hamstrings, and gastrocs. For example, many children with CP have equinovarious contractures of the ankle. While the goal is to optimize stretching, therapies, bracing, and tone management, fixed contractures may require varied levels of intervention to reset the muscle length and improve gait and function. Hip musculature interventions are often aimed at both improving range of motion to help ease caregiver burden on hygiene and or to allow an improved gait pattern, but are also pivotal in hip development and prevention of abnormal formation, subluxation, and dislocation. As noted in the picture, every change in the form and function of bones or of their function alone is followed by certain definite changes in their internal architecture and equally definite secondary alteration in their external conformation. Bony surgical interventions are also often required to maintain alignment and mobility. Goals of osteotomies may include improving joint stability and alignment along with improving joint position and motion for daily function. Common bony interventions include femoral and pelvic osteotomies for improvement of hip subluxation and rotational corrections of the femur and tibia. Foot osteotomies, including arthrodesis or fusions, are often done in adolescents and young adults to help correct unbraceable foot deformities and improve and maintain weight-bearing ability. Interventions for hip subluxation often begin with tone management and may include soft tissue surgeries such as adipose tissue surgery. Interventions for hip subluxation often begin with tone management and may include soft tissue surgeries such as adductor and hamstring lengthenings. If subluxation is 30 to 50%, discussion of hip reconstruction may occur using procedures such as the varus derotational osteotomy and the pelvic osteotomy or DAGA. Hip surveillance, as mentioned before, is an important part of CP management. Surveillance is based on age, mobility level, GMFCS score, gait pattern and type, and previous monitoring. Surveillance frequency is based on a child's age, GMFCS level, and WGH gait type. Surveillance is ideally initiated by two years of age, when a CP diagnosis is provided, or when CP is suspected. Surveillance frequently increases with increasing GMFCS level. Frequency modifiers are based on absolute migration percentage value and percentage change in that percentage value. Discharge criteria for monitoring vary depending on the GMFCS level and gait type. Children with GMFCS levels 3 to 5 and those with a gait type 4 hemiplegia are discharged at skeletal maturity, except for those who have had a migration percentage greater than 30%, or those with pelvic obliquity in the presence of increasing scoliosis, where they are recommended to continue with surveillance. Children at GMFCS levels 1 and 2 are discharged earlier if the migration percentage is stable and under 30%. Here noted is a chart looking at migration percentages, the Melbourne Cerebral Palsy Hip Classification Scale, and an example of measurement of hip migration percentage, which looks at the portion of the femoral head that is no longer covered by the acetabulum. If activity and tone management are not adequate for maintaining appropriate hip alignment and positioning, osteotomies may be indicated. The varus derotational osteotomy of the femur helps improve the varus femoral head, neck, and shaft angle, and redirects the femoral head back into the center of the acetabulum to encourage better joint formation. If the acetabulum itself is too shallow, a pelvic osteotomy such as the daiga may be done to provide improved coverage of the femoral head and correction of excessive femoral antevert. Derotational corrections of the femur and or tibia may also be completed in late childhood or adolescence to correct rotational plane abnormalities that interfere with gait and positioning. Knee flexion contractures may also be problematic, leading to crouched gait and potentially the loss of ambulation or ability to maintain standing. Hamstring lengthenings are generally the first line intervention, but larger interventions such as knee extension osteotomies may be done to preserve function with larger contractures. Foot arthrodesis or planovalgous foot corrections are usually not done until mid to late adolescence after growth is complete, but can be done for those who are unable to be adequately braced for standing and mobility. Corrections such as bunion surgery may also be done as needed. Scoliosis is very common in CP, and the incidence increases with the severity of motor impairments. Children at GMFCS levels 4 to 5 have a 50% or greater chance of developing scoliosis before their 18th birthday, whereas it is rather rare in GMFCS levels 1 and 2. Neuromuscular scoliosis is a rare condition in children under the age of 18. Neuromuscular scoliosis often starts earlier than idiopathic scoliosis and may progress more rapidly. There is no established surveillance program, as there is for the hip, but examination and spinal x-rays should be part of routine care. Most neuromuscular scoliosis develops after age 8, but early or concerning scoliosis may benefit from additional imaging to rule out other neuro-accesses. X-ray evaluation with AP and lateral thoracolumbar views should be done if there is concern for scoliosis on exam. Sitting views are preferred, but supine is adequate for screening. The Cobb angle is used to measure severity of the curve. A curve greater than 10 degrees is indicative of scoliosis. Spinal growth is slower during childhood years and increases rapidly during adolescence, increasing the risk and monitoring need during that time. A curve greater than 40 degrees before age 15, GMFCS level 5, or being bedridden are risk factors for curve progression. Staging and prognostication is also affected by growth. The risk or sign represents the stage of ossification, the process by which new bone is formed, of the iliac crest apotheosis. Capping or closure of the growth plate of the iliac crest happens from lateral to medial, and the growth plate of the iliac crest occurs from lateral to medial. As noted, curvature and progression are generally followed very closely, along with their effects on seating and the patient's respiratory status. It's best to observe the patient's respiratory status before proceeding with a curve. Curvature and progression are generally followed very closely, along with their effects on seating and the patient's respiratory status. Curvature and progression are generally followed very closely, along with their effects on seating and the patient's respiratory status. Spasticity is felt to play a role in the development of scoliosis, but Botox injections or other interventions to paraspinals have been trialed with limited effect. Placement of back within pumps has not been shown to increase scoliosis. As with many bony interventions, it is preferable to wait until post-puberty or later if possible. However, there are other options, including growing rods that may be used for younger patients. This is one example of a significant curve progression over nine months, from 45 degrees to 90 degrees. Bracing can somewhat delay, but does not stop progression of curves. Bracing can somewhat delay, but does not stop progression of curves. Bracing can somewhat delay, but does not stop progression of curves in neuromuscular scoliosis. Bracing can somewhat delay, but does not stop progression of curves in neuromuscular scoliosis. It is frequently used to help with positioning for ADLs and seating comfort, but usually done in a softer or more flexible material. More rigid bracing has been shown to affect the chest anatomy and can be more uncomfortable. Many patients with CP and scoliosis do require surgical intervention. Surgery has improved and evolved over the last decade and now encompasses a robust pre-op, workup, and post-op management plan, including nutrition, respiratory status, and skin monitoring. Patients with CP and neuromuscular scoliosis tend to be more complicated than their peers with ADL scoliosis, as they are at risk for continued progression into adulthood, concurrent pelvic obliquities, osteopenia or poor bone health, more severe curves, and their other corresponding medical comorbidities. Surgery is a large undertaking, especially in a medically complex population. Discussions with family should begin as early as possible as it can be a difficult decision, as well as require adequate time to optimize nutrition and overall health. Palliative care may also be an appropriate team to include at this time to discuss with family their goals of care. Surgery is often recommended as the curve reaches approximately 50 degrees, or if the patient is having rapid progression or any issues related to the scoliosis. However, the hope is to have intervened prior to any significant respiratory, skin, or functional complications. If the curve is moderate and flexible, the most common intervention involves a posterior fusion with hardware. If the curve is more significant or rigid, a two-stage intervention may be necessary with an anterior release followed by a posterior fusion. Surgery has been shown to be effective to correct the deformity and seems to improve patient and caregiver quality of life, though it has not been shown to improve function. The standard surgical intervention generally entails fusion of the scoliotic spinal areas, thoracic and or lumbar, using bone graft, allograft, or autograft from the pelvis. Additional hardware usually includes pedicle screws, wires, or rods are then used to stabilize the spine. Surgery generally decreases the curve by 50 to 75 percent. Growing rod systems are an option for those who are very young to allow for continued spinal growth as well. This concludes the Pediatric Rehabilitation Focus Review covering comorbidities and CP. Thanks for joining us and please let me know if you have any questions or concerns. Thank you.

comorbidities

cerebral palsy

motor impairment

sensation

communication

seizures

orthopedic

scoliosis