Assessment of spinal alignment in children with unilateral cerebral palsy


      • Asymmetry in unilateral cerebral palsy may cause various postural deformities.
      • Scoliosis was observed in 40% of unilateral cerebral palsy children/youths.
      • Children/youths with unilateral cerebral palsy with scoliosis were older.
      • Kyphosis and lumbar lordosis angles were similar in both groups.



      Children/youths with unilateral cerebral palsy are at high risk for the development of scoliosis and other postural deformities. The purpose of this study was to perform spinal assessment in the frontal and sagittal plane using Spinal Mouse® in children/youths with unilateral cerebral palsy and to compare their spinal shape and angles with typically developing children/youths.


      25 children/youths with unilateral cerebral palsy and 25 typical children/youths, aged 6–18 years, were included. The subject's frontal (scoliosis) and sagittal plane (kyphosis and lordosis) spinal curvatures were compared by assessing them with Spinal Mouse®.


      Scoliosis was detected in 40% of subjects in the unilateral cerebral palsy group and this rate was considerably higher than that in typical subjects (12%). The median angle of scoliosis was 8° in subjects with unilateral cerebral palsy and 5.3° in typical subjects. While the median angle of scoliosis was higher in subjects with unilateral cerebral palsy than typical subjects (p < 0.001), there was no significant difference in the angles of lordosis and kyphosis between both groups (p > 0.05). Curvature patterns of subjects with unilateral cerebral palsy differed from typical subjects.


      Our findings will allow children/youths with unilateral cerebral palsy, who are at risk of developing spinal deformity, to be identified earliest possible and included in the intervention. Children/youths with unilateral cerebral palsy have to be assessed in detail from the earliest period, especially when the possibility of an age-related increase in scoliosis is considered.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Biomechanics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Acaröz C.S.
        • Fırat T.
        • Livanelioğlu A.
        Assessment of spinal curvatures in children with upper trunk obstetrical brachial plexus palsy.
        Pediatr. Phys. Ther. 2019; 31: 149-154
        • Addai D.
        • Zarkos J.
        • Bowey A.J.
        Current concepts in the diagnosis and management of adolescent idiopathic scoliosis.
        Child’s Nervous System Jun. 2020; 36: 1111-1119
        • Akbarnia B.A.
        • Yazici M.
        • Thompson G.H.
        The Growing Spine: Management of Spinal Disorders in Young Children.
        Springer Science & Business Media, 2016
        • Alriksson-Schmidt A.I.
        • Arner M.
        • Westbom L.
        • Krumlinde-Sundholm L.
        • Nordmark E.
        • Rodby-Bousquet E.
        • Hägglund G.
        A combined surveillance program and quality register improves management of childhood disability.
        Disabil. Rehabil. 2017; 39: 830-836
        • Ameer M.A.
        • Kamel M.I.
        • Elhafez Y.M.
        A comparison of sagittal spine deformities among elementary school students using spinal mouse device.
        Work (Reading, Mass.). 2019; 64: 545-550
        • Bax M.
        • Goldstein M.
        • Rosenbaum P.
        • Leviton A.
        • Paneth N.
        • Dan B.
        • Jacobsson B.
        Damiano D 2005 proposed definition and classification of cerebral palsy.
        Dev. Med. Child Neurol. April 2005; 47: 571-576
        • Beaman J.K.F.
        • Miller-Skomorucha K.
        The infant and child with cerebral palsy.
        in: Tacklin J.S. Pediatric Physical Therapy. 5th ed. Lippincott Williams & Wilkins, Sydney2015
        • Bertoncelli C.M.
        • Solla F.
        • Loughenbury P.R.
        • Tsirikos A.I.
        • Bertoncelli D.
        • Rampal V.
        Risk factors for developing scoliosis in cerebral palsy: a cross-sectional descriptive study.
        J. Child Neurol. 2017; 32: 657-662
        • Bodkin A.W.
        • Robinson C.
        • Perales F.P.
        Reliability and validity of the gross motor function classification system for cerebral palsy.
        Pediatr. Phys. Ther. 2003; 15: 247-252
        • Boseker E.H.
        • Moe J.H.
        • Winter R.B.
        • Koop S.E.
        Determination of “normal” thoracic kyphosis: a roentgenographic study of 121 “normal” children.
        J. Pediatr. Orthop. 2000; 20: 796-798
        • Cans C.
        Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers.
        Dev. Med. Child Neurol. 2000; 42: 816-824
        • Domagalska-Szopa M.
        • Szopa A.
        Body posture asymmetry differences between children with mild scoliosis and children with unilateral cerebral palsy.
        Biomed. Res. Int. 2013; 462094
        • Gorton 3rd, G.E.
        • Young M.L.
        • Masso P.D.
        Accuracy, reliability, and validity of a 3-dimensional scanner for assessing torso shape in idiopathic scoliosis.
        Spine 15. 2012; 37: 957-965
        • Gu Y.
        • Shelton J.E.
        • Ketchum J.M.
        • Cifu D.X.
        • Palmer D.
        • Sparkman A.
        • Jermer-Gu M.K.
        • Mendigorin M.
        Natural history of scoliosis in nonambulatory spastic tetraplegic cerebral palsy.
        PM&R. 2011; 3: 27-32
        • Hägglund G.
        • Pettersson K.
        • Czuba T.
        • Persson-Bunke M.
        • Rodby-Bousquet E.
        Incidence of scoliosis in cerebral palsy: a population-based study of 962 young individuals.
        Acta Orthop. 2018; 89: 443-447
        • Harrison D.E.
        • Harrison D.D.
        • Cailliet R.
        • Janik T.J.
        • Holland B.
        Radiographic analysis of lumbar lordosis: centroid, cobb, TRALL, and Harrison posterior tangent methods.
        Spine. 2001; 26: E235-E242
        • Himmelmann K.
        • Horber V.
        • Sellier E.
        • De la Cruz J.
        • Papavasiliou A.
        • Krägeloh-Mann I.
        Surveillance of Cerebral Palsy in Europe (SCPE) collaboration. Neuroimaging patterns and function in cerebral palsy-application of an MRI classification.
        Front. Neurol. 2021; 11: 617740
        • Houwink A.
        • Aarts P.B.
        • Geurts A.C.
        • Steenbergen B.
        Neurocognitive perspective on developmental disregard in children with hemiplegic cerebral palsy.
        Res. Dev. Disabil. 2011; 32: 2157-2163
        • Kellis E.
        • Adamou G.
        • Tzilios G.
        • Emmanouilidou M.
        Reliability of spinal range of motion in healthy boys using a skin-surface device.
        J. Manipulative Physiol. Ther. 2008; 31: 570-576
        • Kelly C.
        • Delakis I.
        Technical evaluation of a clinical, bi-planar, digital and upright X-ray imaging unit.
        J. Med. Radiat. Sci. 2021; 68: 475-481
        • Koop S.E.
        Scoliosis in cerebral palsy.
        Dev. Med. Child Neurol. 2009; 51: 92-98
        • Koop S.E.
        • Lonstein J.E.
        • Winter R.B.
        • Denis F.
        The Natural History of Spine Deformity in Cerebral Palsy: In 25th Annual Meeting.
        Scoliosis Research Society, 1991: 24-27
        • Kuznia A.L.
        • Hernandez A.K.
        • Lee L.U.
        Adolescent idiopathic scoliosis: common questions and answers.
        Am. Fam. Physician. 2020; 101: 19-23
        • Lee S.Y.
        • Chung C.Y.
        • Lee K.M.
        • Kwon S.S.
        • Cho K.J.
        • Park M.S.
        Annual changes in radiographic indices of the spine in cerebral palsy patients.
        Eur. Spine J. 2016; 25: 679-686
        • Livanelioglu A.
        • Kaya F.
        • Nabiyev V.
        • Demirkiran G.
        • Fırat T.
        The validity and reliability of “spinal mouse” assessment of spinal curvatures in the frontal plane in pediatric adolescent idiopathic thoraco-lumbar curves.
        Eur. Spine J.: Off. Publ. Eur. Spine Soc., Eur. Spinal Deform. Soc. Eur. Sect. Cerv. Spine Res. Soc. 2016; 25: 476-482
        • Mannion A.F.
        • Knecht K.
        • Balaban G.
        • Dvorak J.
        • Grob D.
        A new skin-surface device for measuring the curvature and global and segmental ranges of motion of the spine: reliability of measurements and comparison with data reviewed from the literature.
        Eur. Spine J.: Off. Publ. Eur. Spine Soc., Eur. Spinal Deform. Soc. Eur. Sect. Cerv. Spine Res. Soc. 2004; 13: 122-136
        • Masaki M.
        • Ogawa Y.
        • Inagaki Y.
        • Sato Y.
        • Yokota M.
        • Maruyama S.
        • Takeuchi M.
        • Kasahara M.
        • Minakawa K.
        • Okamoto M.
        Association of sagittal spinal alignment in the sitting position with the trunk and lower extremity muscle masses in children and adults with cerebral palsy: a pilot study.
        Clin. Biomech. 2021; 105491
        • de Mauroy Jc
        • Weiss Hr
        • Aulisa Ag
        • Aulisa L.
        • Brox Ji
        • Durmala J.
        • Fusco C.
        • Grivas Tb
        • Hermus J.
        • Kotwicki T.
        • et al.
        7th SOSORT consensus paper: conservative treatment of idiopathic & Scheuermann’s kyphosis.
        Scoliosis. 2010; 5: 9
        • McCarthy J.J.
        • D’Andrea L.P.
        • Betz R.R.
        • Clements D.H.
        Scoliosis in the child with cerebral palsy.
        JAAOS-J. Am. Acad. Orthopaed. Surg. 2006; 14: 367-375
        • Morrissy R.T.
        • Goldsmith G.S.
        • Hall E.C.
        • Kehl D.
        • Cowie G.H.
        Measurement of the cobb angle on radiographs of patients who have scoliosis. Measurement of the cobb angle on radiographs of patients who have scoliosis. Evaluation of intrinsic error.
        J. Bone Joint Surg. Am. 1990; 72: 320-327
        • Negrini S.
        • Donzelli S.
        • Aulisa A.G.
        • Czaprowski D.
        • Schreiber S.
        • de Mauroy J.C.
        • Diers H.
        • Grivas T.B.
        • Knott P.
        • Kotwicki T.
        • et al.
        2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth.
        Scol. Spinal Disord. 2018; 13: 1-48
        • Okpala F.
        Measurement of lumbosacral angle in normal radiographs: a retrospective study in Southeast Nigeria.
        Ann. Med. Health Sci. Res. 2014; 4: 757-762
        • Palisano R.J.
        • Rosenbaum P.
        • Bartlett D.
        • Livingston M.H.
        Content validity of the expanded and revised gross motor function classification system.
        Dev. Med. Child Neurol. 2008; 50: 744-750
        • Persson-Bunke M.
        • Hägglund G.
        • Lauge-Pedersen H.
        • Wagner P.
        • Westbom L.
        Scoliosis in a total population of children with cerebral palsy.
        Spine. 2012; 37: E708-E713
        • Persson-Bunke M.
        • Czuba T.
        • Hägglund G.
        • Rodby-Bousquet E.
        Psychometric evaluation of spinal assessment methods to screen for scoliosis in children and adolescents with cerebral palsy.
        BMC Musculoskelet. Disord. 2015; 16: 351
        • Pettersson K.
        • Wagner P.
        • Rodby-Bousquet E.
        Development of a risk score for scoliosis in children with cerebral palsy.
        Acta Orthop. 2020; 91: 203-208
        • Ruthard K.
        • Raabe-Oetker A.
        • Ruthard J.
        • Oppermann T.
        • Duran I.
        • Schönau E.
        Reliability of a radiation-free, noninvasive and computer-assisted assessment of the spine in children with cerebral palsy.
        Eur. Spine J. 2020; 1-6
        • Sato H.
        Postural deformity in children with cerebral palsy: why it occurs and how is it managed.
        Phys. Therapy Res. 2020; 23: 8-14
        • Shamsi M.
        • Veisi K.
        • Karimi L.
        • Sarrafzadeh J.
        • Najafi F.
        Normal range of thoracic kyphosis in male school children.
        Intern. Schol. Res. Notices. 2014; 2014
        • Vogt B.
        • Gosheger G.
        • Wirth T.
        • Horn J.
        • Rödl R.
        Leg length discrepancy- treatment indications and strategies.
        Dtsch. Arztebl. Int. 2020; 117: 405-411
        • Vrtovec T.
        • Pernus F.
        • Likar B.
        A review of methods for quantitative evaluation of spinal curvature.
        Eur. Spine J. 2009; 18: 593-607
        • Willoughby K.L.
        • Ang S.G.
        • Thomason P.
        • Rutz E.
        • Shore B.
        • Buckland A.J.
        • Johnson M.B.
        • Graham H.K.
        Epidemiology of scoliosis in cerebral palsy: a population-based study at skeletal maturity.
        J. Paediatr. Child Health. 2022;
        • Yoshida K.
        • Kajiura I.
        • Suzuki T.
        • Kawabata H.
        Natural history of scoliosis in cerebral palsy and risk factors for progression of scoliosis.
        J. Orthopaed. Sci.: Off. J. Jpn. Orthopaed. Assoc. 2018; 23: 649-652