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Cerebral Palsy in Children: Improving Quality of Life and Preventing Painful Musculoskeletal Disorders

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A special issue of Children (ISSN 2227-9067). This special issue belongs to the section "Pediatric Orthopedics & Sports Medicine".

Deadline for manuscript submissions: 20 August 2026 | Viewed by 10352

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Prof. Dr. Walter Strobl

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Guest Editor

Department for Health Sciences, Medicine and Research, University for Continuing Education Krems, University Clinic Salzburg, and MOTIO, Vienna, Austria
Interests: paediatric orthopaedics; neuro-orthopaedics; child movement development; sensomotor and musculoskletal disorders; interdisiplinary screening and prevention of pain; improving quality of life in neuromotor diseases

Dr. Mathilde Sengölge

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Guest Editor

1. Center for Health Sciences and Medicine, University for Continuing Education Krems, Krems, Austria
2. Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden
Interests: public health; physiotherapy; neuroorthopaedics; scientific publishing
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Dear Colleagues,

Cerebral palsy is the most common cause of movement impairment in childhood. It is a group of disorders caused by a developmental disorder or damage to the developing brain before, during or after birth, which, depending on their severity and localisation, are associated with various sensory and motor dysfunctions and changes in the shape of the locomotor organs. Disorders of walking, standing, sitting, grasping, seeing, hearing, sense of balance, exteroception and proprioception, postural control, communication, cognition, psyche, emotions and behaviour can lead to a considerable reduction in quality of life if pain, restriction of social participation, independence and mobility are present.

In children with cerebral palsy, lack of exercise, non-use and overuse syndromes regularly lead to secondary, initially reversible functional disorders of the sensorimotor system and the locomotor organs and cause musculoskeletal pain. If these are not treated at an early stage, irreversible misalignments of the locomotor system develop with changes in the muscular lever arms, fasciae, joint capsules and deformities as well as dislocations of the joints and bones. The resulting painful neurogenic hyperkyphosis, hyperlordosis, scoliosis, hip dislocations, joint contractures and hand and foot misalignments can usually only be treated palliatively at great expense.

This Special Issue about current research aims to give a deeper understanding of the pathogenesis and possibilities of preventing musculoskeletal pain in children with cerebral palsy.

Numerous studies in recent years have shown that the massive impairment of quality of life caused by these consequential damages can be significantly reduced by screening and secondary preventive measures. There is increasing evidence that new approaches, such as early treatment with verticalisation, movement, supra-threshold strength, coordination and endurance training, postural management and regular sensory input through senso-orthotics, including the stabilisation of unstable joints and exceeding the necessary minimum load and vascularisation of the tissues of the locomotor organs, as well as normal endorphin release, can contribute to pain relief, motivation, physiological sensorimotor development and improvement in quality of life.

We are looking for scientific papers that summarise the current state of knowledge and integrate our own experimental studies and clinical experience in order to provide practitioners and carers with guidance for the treatment of children with cerebral palsy.

Prof. Dr. Walter Strobl
Dr. Mathilde Sengölge
Guest Editors

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Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Children is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2400 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

cerebral palsy
quality of life
musculoskeletal pain
secondary prevention
neuromuscular gait disorders
neuromuscular hip dislocation
neuromuscular scoliosis
early treatment

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Published Papers (7 papers)

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Research

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16 pages, 2371 KB

Open AccessArticle

Knee Joint Loading During Supported Standing in Children and Adolescents with Severe Cerebral Palsy: Effects of Verticalization and Joint Position

by René Althaus and Eva M. Steindl

Children 2026, 13(4), 497; https://doi.org/10.3390/children13040497 - 1 Apr 2026

Viewed by 412

Abstract

Background: Supported standing is widely used in children and adolescents with severe cerebral palsy (CP) as part of rehabilitation programs aimed at maintaining musculoskeletal health and enabling participation. Despite its frequent clinical use, quantitative biomechanical evidence describing knee joint loading under different positioning conditions remains limited, particularly in individuals classified as GMFCS IV–V. The primary objective of this study was to quantify knee joint loading during supported standing across predefined combinations of verticalization angle and hip/knee flexion. The secondary objective was to investigate interaction effects between these variables and to assess whether increasing hip/knee flexion is associated with a linear reduction in knee joint loading. Methods: Twenty-six children and adolescents with CP (GMFCS IV–V; age 6–17 years) participated in the study. Measurements were performed using a standardized back-supported standing device. Knee joint loading was measured using integrated pressure sensors across six verticalization angles (0°, 30°, 45°, 60°, 75°, 90°) combined with four hip/knee flexion angles (0°, 15°, 30°, 45°). Forces were normalized to body weight (%BW). Statistical analysis was performed using repeated-measures analysis of variance. Results: Knee joint loading increased consistently with greater verticalization across all tested hip/knee flexion conditions (p < 0.001). A non-linear pattern was observed across flexion angles. Interaction effects between verticalization and hip/knee flexion were observed. Knee joint loading did not decrease linearly with increasing flexion; instead, the lowest loading was observed at approximately 15° hip/knee flexion, whereas both full extension and 45° flexion resulted in higher loads. Conclusions: Verticalization angle represents a key factor influencing knee joint loading during supported standing in children and adolescents with severe CP. Knee joint loading increases with greater verticalization, while hip/knee position shows a non-linear influence. The absence of a linear reduction in loading with increasing flexion highlights the presence of interaction effects between positioning variables and supports individualized positioning strategies in supported standing programs. Full article

(This article belongs to the Special Issue Cerebral Palsy in Children: Improving Quality of Life and Preventing Painful Musculoskeletal Disorders)

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13 pages, 3356 KB

Open AccessArticle

Foot Weight-Bearing in Supported Standing: Influence of Verticalization Angles and Hip/Knee Flexion in Children and Adolescents with Cerebral Palsy (GMFCS IV-V)

by Eva M. Steindl and René Althaus

Children 2026, 13(3), 346; https://doi.org/10.3390/children13030346 - 27 Feb 2026

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Abstract

Background: Supported standing is commonly prescribed for children and adolescents with cerebral palsy (CP) to support musculoskeletal health and participation. However, objective data on plantar loading under different positioning conditions are limited, particularly in individuals with severe motor impairment (GMFCS IV–V). This study quantified plantar loading as an operational measure of foot weight-bearing during supported standing across combinations of verticalization angle and hip/knee flexion. Methods: Twenty-six children and adolescents with CP (GMFCS IV–V; 6–17 years) were assessed using a standardized back-supported standing system. Plantar loading was measured with two calibrated force plates at six verticalization angles (0°, 30°, 45°, 60°, 75°, 90°) combined with four hip/knee flexion angles (0°, 15°, 30°, 45°). Loading was expressed as a percentage of body weight (% BW). Effects were analyzed using repeated-measures analysis of variance. Results: Plantar loading increased progressively with increasing verticalization angles across all hip/knee flexion conditions. Clinically relevant loading levels (>70% BW) were achieved at a verticalization angle of 60° in most flexion conditions. Maximum plantar loading was observed at 90° verticalization combined with 30° hip/knee flexion (96.4% BW). At 90° verticalization, plantar loading remained substantial even with 45° hip/knee flexion (81.4% BW). Increasing hip/knee flexion did not result in a linear reduction in plantar loading; a significant decrease was observed only at 45° flexion. Conclusions: Verticalization angle is the primary determinant of plantar loading during supported standing in children and adolescents with severe CP. Clinically meaningful plantar loading—and thus effective foot weight-bearing—can be achieved at moderate verticalization angles despite hip and knee flexion, supporting flexible positioning strategies. Full article

(This article belongs to the Special Issue Cerebral Palsy in Children: Improving Quality of Life and Preventing Painful Musculoskeletal Disorders)

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11 pages, 1552 KB

Open AccessArticle

A Traffic Light System for Detecting Spinal Deformities in Children with Cerebral Palsy

by Bettina Westhoff, Björn Vehse, Kell Behrens, Melanie Horter, Reza Pasha, Richard Placzek, Urs von Deimling, Tamara Seidl and Daniel Herz

Children 2025, 12(10), 1315; https://doi.org/10.3390/children12101315 - 30 Sep 2025

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Abstract

Background/Objectives: Currently, clinicians and physiotherapists pay only limited attention to spinal deformities in children with cerebral palsy (CP). To enhance awareness, a tool based on a traffic light system (TLS-Spine) was developed for use by pediatricians and physiotherapists caring for children with CP. The objective of the study was to evaluate the applicability of this assessment tool in routine clinical practice. Methods: A review group consisting of 48 pediatricians and physiotherapists was recruited. Each participant was asked to apply the TLS-Spine to a minimum of 10 CP patients and to complete a questionnaire concerning its value and applicability in daily practice. Responses were rated on a scale from 1 (complete agreement) to 6 (complete disagreement). Results: The TLS-Spine was correctly applied in 96.3% cases. The questionnaires of 48 reviewers based on 537 completed survey sheets were analyzed. Overall, reviewers reported no difficulties with the introduction and use of the TLS-Spine in daily clinical routine practice (median/range: 1/1–4). The tool was considered straightforward to use (1/1–3), not time consuming (1/1–4), helpful in performing the clinical examination (2/1–6), understanding the findings (2/1–6) and deciding on further management of the patients (2/1–5). Physicians rated the TLS-Spine significantly higher than physiotherapists in four of nine dimensions. Conclusions: The TLS-Spine is a practical and user-friendly assessment tool. It may increase the awareness for spinal deformities and support early referral to orthopedic specialists for early detection and treatment. Full article

(This article belongs to the Special Issue Cerebral Palsy in Children: Improving Quality of Life and Preventing Painful Musculoskeletal Disorders)

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13 pages, 951 KB

Open AccessArticle

Evaluation of Acetabular Defects in Children with Cerebral Palsy: A Comparative Analysis of CT Measurements and Radiographic Parameters

by Domenic Grisch, Olivier Weber, Britta K. Krautwurst, Franziska L. Hatt, Michael Zellner, Christian von Deimling, Tobias Götschi, Bastian Sigrist and Thomas Dreher

Children 2025, 12(9), 1254; https://doi.org/10.3390/children12091254 - 17 Sep 2025

Viewed by 926

Abstract

Objectives: This retrospective study examines acetabular morphology and defects in children with cerebral palsy (CP). The study discovers the usefulness and reliability of a reconstructed 3D CT measurement technique and compares it to conventional radiographic measurements. Methods: 33 subjects with CP who underwent hip reconstruction, including Dega osteotomy and varus derotation femoral osteotomy, were included and compared to an age-matched group of 42 typically developing children. We reproduced a three directional acetabular index (3DAI), including anterosuperior, superolateral and posterosuperior indices in CT analysis, and compared them with established radiographic measurements for the migration percentage (MP) and the acetabular index (AI). Results: The results showed significantly higher 3DAI in every direction of wall deficiency, accentuating the methods sensitivity for acetabular dysplasia. The interrater and test–retest reliability were robust with ICC = 0.939–0.988 for the CP group. Conventional radiographic measurements demonstrated better discriminative power for identifying hip dislocation and correlated strongly with the 3DAI (p < 0.001). Conclusions: The 3DAI method showcases an important addition to the conventional radiographic measurements by enabling a quantification of the defect amount and direction for operative planning. The study supports the potential of a 3D analysis in the improvement of diagnostic precision and suggests a continuous refinement of the CT measurement technique. Full article

(This article belongs to the Special Issue Cerebral Palsy in Children: Improving Quality of Life and Preventing Painful Musculoskeletal Disorders)

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12 pages, 236 KB

Open AccessEditor’s ChoiceArticle

by Chris Church, Sana Patil, Stephanie Butler, Freeman Miller, Jose J. Salazar-Torres, Nancy Lennon, M. Wade Shrader, Maureen Donohoe, Faithe Kalisperis, W. G. Stuart Mackenzie and Louise Reid Nichols

Children 2025, 12(3), 365; https://doi.org/10.3390/children12030365 - 15 Mar 2025

Cited by 4 | Viewed by 2259

Abstract

Background: The use of patient-reported outcomes is essential to understand and manage health-related quality of life (HRQOL) in youth with lifelong disabilities. This study evaluated HRQOL in youth with physical disorders and examined its relationship with mobility. Methods: We conducted an IRB-approved retrospective study in which we administered the parent-reported Pediatric Outcomes Data Collection Instrument (PODCI) and Gross Motor Function Measure section D (GMFM-D) to ambulatory youth aged 2–18 years with cerebral palsy (CP; Gross Motor Function Classification System II; n = 258), arthrogryposis (n = 138), achondroplasia (n = 102), and Morquio syndrome (n = 52) during clinical visits to a gait lab. The PODCI has two validated versions, child and adolescent, that assess perceptions about mobility, happiness, and pain. Differences in HRQOL between diagnostic groups, between age groups, and compared with non-disabled youth were examined using non-parametric tests. The relationship between GMFM-D and PODCI scores was analyzed with Pearson’s correlations. Results: Both age cohorts within all diagnosis groups demonstrated higher pain and lower mobility compared with non-disabled youth (p < 0.015). Happiness was lower for both age groups with CP and arthrogryposis, and for the child group with Morquio syndrome compared with non-disabled youth (p < 0.002). In diagnostic groups in both age spans, Global Function was higher (p < 0.0001) for those with achondroplasia compared with other groups. Despite functional differences, there were no significant differences between diagnostic groups in pain scores (p > 0.10). Happiness was lower in the group with CP compared with that with achondroplasia (p = 0.01). GMFM-D was related to PODCI mobility scores for all diagnoses (r = 0.31 to 0.79, p < 0.03) but was not correlated with happiness (r = −0.16 to 0.092; p > 0.14); GMFM-D and PODCI pain scores were associated only for the child group with achondroplasia (r = 0.355; p < 0.001). Conclusions: Significant limitations in HRQOL are present in youth with physical disabilities. Pain levels were higher than those of non-disabled youth, but pain was not related to lower motor function. Happiness was not related to gross motor function, suggesting the need to examine other factors when mental health concerns are present in youth with disabilities. Full article

(This article belongs to the Special Issue Cerebral Palsy in Children: Improving Quality of Life and Preventing Painful Musculoskeletal Disorders)

Review

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10 pages, 2254 KB

Open AccessReview

The Often-Unmentioned Key Points of Orthotics—A Short Comment

by Reinald Brunner

Children 2025, 12(9), 1154; https://doi.org/10.3390/children12091154 - 29 Aug 2025

Viewed by 781

Abstract

Orthoses are a vital part of treating gait disorders, especially in children and adolescents with neurological and neuromuscular conditions. For proper walking, the supporting leg must be stable to allow the other leg to swing forward and take a step. Stability is also essential for motor development. This stability depends on the inclination of the tibia, which needs to be kept upright during mid-stance in both the sagittal and coronal planes. Controlling the load axis in all planes and the foot in the transverse plane helps maintain proper tibial control. More studies are now examining the effects different orthoses and designs. While much focus has been on the sagittal plane, there is much less information about how orthoses influence the coronal plane or foot control. As a result, there is limited guidance from the existing literature. Children who find it hard to express discomfort or negative effects may simply reject orthoses altogether. This paper explains how important proper tibia inclination and control on the load axis are in all planes and how they affect stability. The foot acts as a lever for the gastrosoleus muscle, which controls the tibia. In case of foot instability or deformity, the foot requires support that takes into account the changing load when walking. I also emphasize that these points are regularly considered when studies are reported. Full article

(This article belongs to the Special Issue Cerebral Palsy in Children: Improving Quality of Life and Preventing Painful Musculoskeletal Disorders)

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14 pages, 14232 KB

Open AccessReview

Cerebral Palsy Link to Sensorimotor System, Cognition, Emotion and Nociplastic Pain

by Wolfgang Laube and Mathilde Sengoelge

Children 2025, 12(6), 702; https://doi.org/10.3390/children12060702 - 29 May 2025

Cited by 1 | Viewed by 2417

Abstract

This narrative review provides an overview of the link between the sensorimotor system, cognition, emotion and pain syndromes in persons due to deconditioning or delayed sensorimotor development, then applied to persons with cerebral palsy (CP). The brain damage that occurs before, during or even after birth pathophysiologically alters the structure and subsequent function of the sensorimotor function, which is inseparably linked to cognition, emotion, behavior and pain. This damage results in a functional developmental disorder that also affects the structure and function of the neuromatrix in a graded manner due to chronic deconditioning. It is the basis for both primary and secondary chronic degenerative diseases. This leads to an increasing prevalence of chronic pain syndromes, which may be very high in persons with CP. Thus, CP is both a disposing factor and a causal factor for nociplastic pain, defined as persistent pain arising from altered nociception without evidence of tissue or somatosensory damage. Therapy interventions are crucial to optimize movement, cognition and emotion, as well as pain reduction in persons with CP. Full article

(This article belongs to the Special Issue Cerebral Palsy in Children: Improving Quality of Life and Preventing Painful Musculoskeletal Disorders)

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