Musculoskeletal means muscles and bones. There are some common problems with muscles and bones that people with physical disabilities experience. The problems should not be ignored. 

Foot Pain

Foot pain often happens when changes in the bones and joints of the foot occur and stop them working how they are supposed to. 

Why is it important that I manage my foot pain?

Foot pain will stop you doing what you want and need to do. 

You need a safe, stable and pain free base to transfer and walk. 

Working out the problems early and finding ways to stop the changes getting worse can help you to keep doing what you want to.

What can I do?

Speak to your GP and allied health team, they will work together to help you.

Physiotherapists will assist you to manage your pain and look at your walking and transfers to find the best way to move for you. 

Podiatrists are experts in feet and the movements and health related to the lower limb. They will assist you to manage pain and may prescribe foot orthotics.

Orthotists prescribe and manufacture various orthoses that can help prevent changes in the foot and ankle and slow any further changes. Orthotists work closely with physiotherapists to achieve your goals.

As many people with physical disabilities have many joints involved, most will need to see an orthotist for orthotics.

A referral to an orthopaedic surgeon is needed if the changes in your joints mean that surgery may help you prevent or manage pain. It is important to ask this question in your teen and early adult years. Once you are older and many changes have occurred, surgery unfortunately is often not an option.

Physiotherapists and occupational therapists can help you find the best mobility for you. This could be walking independently around the home, a walker for short distances and a wheelchair or scooter for long distances or any combination. 

Knee Pain

Knee pain often occurs in people with cerebral palsy when the large front thigh muscles are over working. It is most common in people who have spastic diplegia type cerebral palsy. Patella alta and arthritis in the knee and patella (knee cap) are a very common reasons for pain in cerebral palsy felt in the teenage years and in adulthood.

What can I do to prevent knee pain?

• See your physiotherapist regularly for walking advice, stretching and strengthening and guidance on how best to move.
• See an orthopaedic surgeon for yearly reviews to monitor your needs. Surgery to change the line of your muscles and the position of your joints and bones may benefit you.
• Seek help for any pain as soon as it happens.

What do I do if I get knee pain?

• See your doctor for advice on medications to help with pain.
• See your physiotherapist as soon as possible for review and management of your current pain and to find ways to reduce the pain happening again.
• If pain continues despite all conservative management, see an orthopaedic surgeon for advice.

Hip Pain

Pain in the hips can happen when your hips are not in their joint position properly (called hip displacement) or changes within the joint has occurred e.g. arthritis.

What is hip displacement?

Hip displacement is when the top part of the thigh bone moves out of the hip joint. This means that the hip joint does not work well and this can cause wear and tear on the bones. This causes arthritis which causes pain.

What can I do?

The first step is to stop it ever happening!

• If you cannot keep your knees apart with your feet together when you are sitting and standing then you are at risk of hip pain.
• Physiotherapists and occupational therapists can support you with exercise programs and different positions to go into during the day and night. These will help your hip stay in position and slow down the wear and tear on your bones.
• Hip monitoring by hip x-rays should occur until you stop growing. This is because hip displacement is often silent and is not known unless reviewed on x-rays. If you continue to be at high risk of hip displacement into adulthood, ask your GP for ongoing hip x-ray monitoring. The images of the x-rays and the report should be shared with your physiotherapist to monitor and help plan what you need.

If you have pain in your hips, speak to your general practitioner (GP) and allied health team. 

• Get an x-ray of the hip joint to review the hip position. Share both the images of the x-ray and the report with your physiotherapist.
• See your GP for oral medication and other pain relief recommendations.
• See your physiotherapist as soon as possible for review and pain management strategies.
• See your physiotherapist and occupational therapist to have all your equipment and different positions for day and night reviewed.
• A referral to an orthopaedic surgeon may be indicated for management of the hip pain. 

Scoliosis

Scoliosis refers to a curvature of the spine. It means that there is more than a 10 degree curve of the spine on an x-ray of a spine. 

Scoliosis can occur in 15% to 80% of people with neuromuscular conditions. 

People who have spasticity across their whole body are most at risk. 

The curve can get worse as you get older. Monitoring is very important to catch changes before they become worse. 

What are the effects of scoliosis in cerebral palsy?

• Pain: especially in the back and shoulders.
• Windswept deformity: describes a person’s position where the knees go to one side and it is very difficult to move or control the knees to go to the other side. The pelvis also often does not position properly. 
• Rib changes: large rib changes result in parts of the ribs rubbing against objects or the pelvis. This often causes pain, skin breakdown and pressure injury. 
• Positioning difficulties: the above positions make it difficult to sit and lie down. There is an increased chance of hip displacement and pressure on one side of the bottom which can cause skin breakdown and pressure injury (e.g. ulcers).
• Respiratory and gastrointestinal problems: a scoliosis can affect how your organs work meaning it is harder to take deep breaths, cough, swallow and digest your food. Chest infections, heartburn, reflux and constipation are often experienced by people with scoliosis. 
• Swallowing problems and underweight: experienced by many people with scoliosis who do not complete standing transfers or walk.

What are the options to manage a scoliosis?

Non-surgical options include customized seating systems that provide external support to the spine or spinal bracing or a combination of both.

Will bracing help?

During the growing years, it has been shown that spinal bracing can reduce curve size and slow down the rate of progression to larger curves. However it is unclear if bracing can stop progression.

In adulthood, a spinal brace can help improve sitting and the ease of positioning. However, it is not known what the effects of a brace are in adulthood. Some people find comfort in wearing a brace while others find it too uncomfortable to wear. Monitoring and a team approach including orthopaedic surgeon, orthotists, physiotherapist and occupational therapist is best when deciding whether bracing into adulthood is best for you.

Customised seating

Customised seating means that the support you have in your chair is made just for you, supporting your body in the way it needs to be supported.

Physiotherapists and occupational therapists prescribe seating that will best support you. Supports aim to slow progression however it is unlikely to stop progression. The strength of spasticity, the effects of gravity on your body and the need to allow movement and comfort mean that it is not possible to completely stop your body from changing.

What are the surgical options?

Your orthopaedic surgeon may recommend a spinal fusion. This is where the bones in the back will be fused together. Your surgeon will discuss the surgical options with you in detail. 

What should I do if I have or am at risk of scoliosis?

See your physiotherapist for yearly reviews to pick up and manage any changes. People of all abilities can develop scoliosis, everyone with a physical disability should see a physiotherapist for a yearly review.

Have your equipment reviewed every year by your health professional team to make sure it is still supporting you.

Have all your positions used during the day and night reviewed every year by your physiotherapist and occupational therapist to make sure they are still right for you.

Have a swallowing review with a speech pathologist each year to make sure you swallow safely.

See a dietitian for help to make sure you get the right amount of food.

Cervical Stenosis

Cervical stenosis is a narrowing of the spinal column in the neck. The space that is around the spinal column becomes thinner as the bones change position. Studies have found that people with athetoid type cerebral palsy have a greater risk of cervical stenosis. Clinically, cervical stenosis has occurred in people with cerebral palsy who have asymmetry ie a difference on each side of the body.

What are the effects of cervical stenosis in cerebral palsy?

• If the narrowing of the spinal column is large combined with heightened spinal changes such as disc degeneration and instability, it can mean that the spinal cord could be stopped from sending messages down the spine. 
• This means people can experience a fast decrease in function and devastating neurological impairment.
• Put simply, if cervical stenosis is not picked up, people can go from being independent with walking and transfers to having quadriplegia within a very short space of time.

What do I need to do to make sure I am not at risk?

• Be monitored by physiotherapy every year regardless of your abilities. While studies do indicate that those with athetoid type cerebral palsy are at greater risk, people with spastic and hemiplegia type cerebral palsy have also experienced deterioration.
• Ask your physiotherapist to complete a neurological power and sensory assessment every year and more often if you show signs of cervical stenosis. 
  • This type of assessment looks at your sensation, your reflexes and your strength in your muscles that are distributed by each spinal level. 
• If you experience a sudden change in your abilities, see your doctor and physiotherapist immediately and consider attending the emergency department if you cannot walk or transfer or feel parts of your body that you could previously do.
• If you already know that you are at risk of cervical stenosis and experience a sudden change, go immediately to the emergency department.
• If you experience a sudden change in your bladder and bowel control, see your doctor immediately. If this change occurs with changes in your abilities, attend the emergency department immediately.
• If you experience a change in what you can feel, numbness, pins and needles, especially if they occur in both hands or both legs, see your doctor and physiotherapist as soon as possible for review.
• See the Future Thinking website for information on knowing Your Normal. Your therapy team and doctor can help you to write down what your normal is. Knowing your normal can make it easier to explain to health professionals that what you are experiencing is a big change and that it is not related to your cerebral palsy.

What happens if I do get neurological changes because of cervical stenosis?

• Surgical intervention is the only option to restore your function and prevent you deteriorating further.
• A neurosurgeon will assess you and determine the best approach to support you.
• Intensive rehabilitation will occur after your surgery.
• People who have had surgery have varied results as it depends on how quickly the problems are picked up and the extent of the problems. People who have had their problems picked up early are more likely to return to close to their original function.

Upper Limb Pain

Pain in your upper limb – anywhere from your neck down to your fingers can affect how you do many activities. Pain in shoulders and elbows can stop you from being as independent as you could be.

Why is it important that I manage my upper limb pain?

Think about all the activities you do with your arms and hands. Imagine how you would do these if you arms and hands were not able to do them. 

Many people with physical disabilities rely on their arms for transfers and walking, for example holding onto rails to transfer independently or when using elbow crutches or a four wheeled walker. Often people seek help because their shoulders are painful and they are not able to transfer or walk how they have in the past.

What can I do?

Upper limb pain often starts as a discomfort and gradually increases. 

Don’t ignore the pain. Take action and seek support as soon as possible.

Try to avoid getting pain in the first place. 

Ask for a review by physiotherapy and occupational therapy to find the best way to do these tasks:

• Transfers
• Walking
• Shopping and carrying heavy objects
• Hanging out your washing and lifting objects above your head
• Cleaning and moving your arms away from your body.

Therapists will treat your pain and provide various techniques like stretching, strengthening, massage, exercise, postural training and review of all activities.

Consider other mobility devices

Many people think about how long they will be able to walk as they get older. For those that rely on their arms for transfers or walking, often the reason they are likely to stop transferring or walking is because their shoulder pain stops them rather than their legs.

To find balance and to manage your pain, using different mobility devices can help. Using a scooter or power wheelchair can give your arms a rest and help them recover. 

Using a mobility device does not mean you won’t continue to walk. For many, it is likely that you will be able to walk for more years than you would have if you didn’t use a mobility device.

Consider support from support workers

Another way to find balance is having someone else help you with the heavier or harder jobs. Getting help to carry heavy shopping bags, hang out washing, do the vacuuming and gardening can mean you can continue to do other activities.