Walking abilities of young adults with cerebral palsy: changes after multilevel surgery and adolescence

Mobility and gait in adults with cerebral palsy: Evaluating change from adolescence

BACKGROUND

Previous studies have looked at the short-term effectiveness of conservative and surgical treatment of children with cerebral palsy (CP), but few have explored the long-term outcomes into adulthood using gait analysis and patient-reported outcome measures.

RESEARCH QUESTION

How do gait, mobility, and patient-reported outcomes in adults with CP who received specialized pediatric orthopedic care change from adolescence?

METHODS

We identified 645 adults with 1) CP, 2) age 25-45 years, and 3) an adolescent instrumented gait analysis (IGA) at our center. Measurement outcomes included physical examination, IGA, and select domains of the Patient-Reported Outcomes Measurement Information System (PROMIS).

RESULTS

Participants included 136 adults with CP; Gross Motor Function Classification System levels I (21 %), II (51 %), III (22 %), and IV (7%); 57 % males; and average age 16 ± 3/29 ± 3 years (adolescent/adult visits). There was no significant difference in gait deviation index, stride length, or gross motor function between adolescent and adult visits. There were statistically significant but not clinically meaningful declines in gait velocity. At adulthood, PROMIS results revealed limitations in physical function compared with a normative sample but no differences in depression, participation, or pain interference.

SIGNIFICANCE

In this relatively homogeneous group of adults with CP who received orthopedic care from one center, gait and gross motor function showed no clinically meaningful change from adolescence, which differs from recent reports of declining mobility in adulthood. Expert orthopedic care, guided by IGA, may prevent losses in functional mobility for adults with CP.

Factors associated with walking activity in adults with cerebral palsy

BACKGROUND

This prospective study used instrumented gait analysis, patient-reported outcomes, and portable accelerometers to examine walking activity in adults with cerebral palsy (CP).

RESEARCH QUESTION

This study aimed to provide objective data and evaluate factors associated with walking activity in adults with CP.

METHODS

Participants with CP (ages 25-45 years) completed instrumented gait analysis and patient-reported outcomes, including the Patient Reported Outcome Measurement Information System (PROMIS) and Satisfaction with Life Score (SWLS), and wore a StepWatch for 8 days. Average strides per day, stratified by Gross Motor Function Classification System (GMFCS), were compared with nondisabled adults ages 30-39 years utilizing Welch's t-tests with Bonferroni corrections. Correlation coefficients and stepwise multiple linear regression analyses examined relationships between walking activity and GMFCS, gait deviation index (GDI), gait velocity, PROMIS physical function, SWLS, body mass index (BMI), and employment.

RESULTS

Participants included 109 adults with CP, ages 29 ± 4 years, classified at GMFCS levels I/II (73 %) and III/IV (27 %). Compared with nondisabled adults, daily stride count was significantly lower in both groups of adults with CP (p < 0.00025), with a progressive decline according to GMFCS level. Walking activity correlated with PROMIS physical function (r = .42), GDI (r = .48), and gait velocity (r = .58). Association for employment was lower (r = 0.27) but significant, while age, SWLS, and BMI were not individually correlated with walking activity. Stepwise, multiple linear regression modeled with Akaike information criterion explained 40.9 % of the observed variability in walking activity in this cohort of adults with CP.

SIGNIFICANCE

Physical function, as classified by GMFCS or measured by PROMIS and self-selected walking velocity, has the strongest association with and is the most significant predictor of walking activity in adults with CP. After accounting for physical function, a small amount of the variation in walking activity can be explained by GDI, employment, and age.

Follow-up of walking quality after end of growth in 28 children with bilateral cerebral palsy

PURPOSE

Assessment of surgical treatments on gait in patients with bilateral cerebral palsy (CP) is often performed in short-term studies. The purpose of this study was to analyze the influence of single-event multilevel surgery (SEMLS) on long-term evolution of gait using gait deviation index (GDI) and walking speed.

METHODS

In all, 28 patients with bilateral CP (Gross Motor Function Classification System I to III) with two clinical gait analyses (CGA) were included (mean age: 9.0 years (sd 2.9) at the first CGA, 19.6 years (sd 4.1) at the last, all of them at skeletal maturity). GDI, walking speed and their changes were calculated. Statistical analysis was performed to observe differences between baseline and follow-up CGA. Pearson's correlations were conducted to evaluate the associations between GDI and walking speed changes with: GDI at baseline and walking speed at baseline. GDI and walking speed evolution have been analyzed for two groups of patients: with and without SEMLS.

RESULTS

Regardless of the treatment, GDI was significantly higher at follow-up CGA (baseline: 73.1 (sd 13.1) versus follow-up: 80.1 (sd 13.2); p = 0.014). Significant negative correlations were found between GDI change and GDI at baseline (r = -0.52; p = 0.004) and between walking speed change and walking speed at the baseline (r = -0.70; p < 0.001). Regarding the group of patients with or without SEMLS, only significant improvement of GDI was found for patients with SEMLS (at baseline: 69.0 (sd 12.1) versus follow-up: 77.8 (sd 11.2); p < 0.05).

CONCLUSION

Analysis at skeletal maturity showed a gait quality maintained for patients without SEMLS and an improvement for patients with SEMLS.

LEVEL OF EVIDENCE

Level III.

Multilevel Surgery for Children With Cerebral Palsy: A Meta-analysis

CONTEXT

Multilevel surgery (MLS) is standard care for reducing musculoskeletal disorders among children with spastic cerebral palsy (CP).

OBJECTIVE

To summarize the literature examining effects of MLS and satisfaction with MLS for children with CP.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched.

STUDY SELECTION

Studies in which authors reported effects of or satisfaction with MLS in children with CP were selected.

DATA EXTRACTION

Two authors screened and extracted data on gross motor function, gait speed, gait (eg, Gait Profile Score), range of motion, strength, spasticity, participation, quality of life, satisfaction, and adverse events.

RESULTS

Seventy-four studies (3551 participants) were identified. One was a randomized controlled trial (RCT) (n = 19); the remainder were cohort studies. Pooled analysis of cohort studies revealed that MLS did not have a long-term effect on gross motor function (standardized mean difference [SMD]: 0.38; 95% confidence interval [CI]: -0.25 to 1.01) or gait speed (SMD: 0.12; 95% CI: -0.01 to 0.25) but did improve gait (SMD: -0.80; 95% CI: -0.95 to -0.65). The RCT also revealed no effect of MLS on gross motor function but improvements in the Gait Profile Score at 1 year. Participation and quality of life were reported in only 5 studies, and adverse events were adequately reported in 17 studies.

LIMITATIONS

Data were largely from cohort studies.

CONCLUSIONS

Findings reveal that gait, but not gross motor function, improves after MLS. RCTs and improved reporting of studies of MLS are required.

Equinus Correction During Multilevel Surgery in Adults With Cerebral Palsy

BACKGROUND

Equinus foot deformity constitutes a common gait disorder in ambulatory adults with bilateral spastic cerebral palsy (BSCP). The outcome after intramuscular aponeurotic lengthening in the context of single-event multilevel surgery (SEMLS) in adulthood has not been investigated.

METHODS

We followed a group of 31 ambulatory adults with BSCP and equinus who underwent SEMLS including gastrocnemius-soleus intramuscular aponeurotic recession or Achilles tendon lengthening. All patients were analyzed preoperatively and at least 1 year (mean follow-up period: 1.6 years) postoperatively by clinical examination and 3-dimensional instrumented gait analysis including the Gait Profile Score (GPS).

RESULTS

Clinical examination showed no significant improvement of ankle dorsiflexion ( P = .5) and an unchanged plantarflexion ( P = .7) with knee extended but a significant postoperative reduction of spasticity in the calf muscle ( P = .0001) as measured by clinical examination following the modified Ashworth scale. Significant improvement of mean ankle dorsiflexion in stance and swing ( P = .0001) was found. The GPS decreased and improved significantly (15.9 ± 4.6 to 11.4 ± 3.1; P = .0001). Persistence of equinus and calcaneal gait indicating under- and overcorrection at follow-up was found in 1 patient (3%), respectively.

CONCLUSION

Intramuscular gastrocnemius-soleus aponeurotic recession is part of multilevel surgery corrected equinus deformity in adults. The increase in muscle length led to significant improvement of kinetic and kinematic parameters during walking without a loss of muscle strength and push-off capacity. The risk of overcorrection after equinus correction in adults with BSCP was found to be relatively low.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Patient-reported mobility function and engagement in young adults with cerebral palsy: a cross-sectional sample

PURPOSE

To describe self-reported life satisfaction and motor function of young adults with cerebral palsy (CP).

METHODS

A total of 57 young adults with spastic CP classified as levels I (seven), II (25), III (16), IV (nine) by the Gross Motor Function Classification System, followed from childhood by our CP clinic, returned at a mean age of 27 years two months (SD 3 years 4 months). Self-reported life satisfaction and mobility status were measured by the Pediatric Outcomes Data Collection Instrument (PODCI), Patient-Reported Outcomes Measurement Information System (PROMIS), Functional Mobility Scale (FMS) and a project questionnaire. Surgical history and childhood mobility were confirmed from medical records.

RESULTS

The Functional Mobility Scale demonstrated limited but stable mobility function from childhood to adulthood. The PROMIS and PODCI revealed limited motor function compared with a non-disabled normative reference (p < 0.05). Descriptive results showed high dependence on transportation, housing and income; although PROMIS subscales revealed satisfaction with social activities. Self-recall of childhood mobility function using the FMS correlated highly (r = 0.8; p < 0.0001) with historical records.

CONCLUSION

Although functional mobility is limited and community independence is not fully achieved in young adults with CP, these participants maintained childhood levels of mobility function into young adulthood, were satisfied with social roles and had minimal reports of pain.

Flexed-knee gait in children with cerebral palsy

Aims

The purpose of this study was to evaluate the long-term outcome of adolescents with cerebral palsy who have undergone single-event multilevel surgery for a flexed-knee gait, followed into young adulthood using 3D motion analysis.

Patients and Methods

A total of 59 young adults with spastic cerebral palsy, with a mean age of 26 years (sd 3), were enrolled into the study in which their gait was compared with an evaluation that had taken place a mean of 12 years (sd 2) previously. At their visits during adolescence, the children walked with excessive flexion of the knee at initial contact and surgical or therapeutic interventions were not controlled between visits.

Results

Based on the change in flexed-knee gait over approximately ten years, improvements were seen in increased Gait Deviation Index (p < 0.001) and decreased flexion of the knee at initial contact (p < 0.001). Greater popliteal angle (p < 0.001), reduced Gross Motor Function Measure section D (p = 0.006), and reduced speed of gait (p = 0.007) suggested a mild decline in function. Quality-of-life measures showed that these patients fell within normal limits compared with typical young adults in areas other than physical function.

Conclusion

While some small significant changes were noted, little clinically significant change was seen in function and gait, with gross motor function maintained between adolescence and young adulthood. Cite this article: Bone Joint J 2018;100-B:549–56.

Effects of multilevel surgery on a flexed knee gait in adults with cerebral palsy

Aims

A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood.

Patients and Methods

At a mean of 22.9 months (standard deviation 12.9), after single event multi level surgery, 3D gait analysis was undertaken pre- and post-operatively for 37 adult patients with bilateral cerebral palsy and a fixed knee gait.

Results

There was a significant improvement of indices and clinical and kinematic parameters including extension of the hip and knee, reduction of knee flexion at initial contact, reduction of minimum and mean knee flexion in the stance phase of gait, improved range of movement of the knee and a reduction of mean flexion of the hip in the stance phase. Genu recurvatum occurred in two patients (n = 3 legs, 4%) and an increase of pelvic tilt (> 5°) was found in 12 patients (n = 23 legs, 31%).

Conclusion

Adult patients with bilateral cerebral palsy and a flexed knee gait benefit from multilevel surgery including hamstring lengthening. The risk of the occurence of genu recurvatum and increased pelvic tilt is lower than has been previously reported in children. Cite this article: Bone Joint J 2017;99-B:1256–64.

Factors influencing outcomes after medial hamstring lengthening with semitendinosus transfer in patients with cerebral palsy

BACKGROUND

Although several studies have investigated the outcomes after distal hamstring lengthening (DHL), no study has undertaken an approach that included all or most of the important factors that could influence the results. This study was performed to evaluate the outcomes after DHL and analyze the factors that influence the improvement and serial change in knee motion after surgery in patients with cerebral palsy (CP), using a linear mixed model (LMM).

METHODS

The study included 314 ambulatory CP patients (594 limbs) with spsastic diplegia who were followed up after undergoing DHL as part of a single-event multilevel surgery and who underwent preoperative and postoperative 3-dimensional (3D) gait analyses. Relevant kinematic values, including knee flexion at initial contact, minimum knee flexion in the stance phase, knee range of motion (ROM), mean pelvic tilt and gait deviation index (GDI) score, were the outcome measures. Changes in knee motion and the GDI score were adjusted for multiple factors, such as sex, the Gross Motor Function Classification System (GMFCS) level, and concomitant surgeries as fixed effects, and follow-up duration, laterality, and each subject as random effects, using a LMM.

RESULTS

We found significant improvements in knee flexion at initial contact, minimum knee flexion in the stance phase, knee ROM, and GDI score 2 years after DHL. In patients with GMFCS level I and II, improvement in all sagittal knee kinematics was maintained during follow-up. In addition, GDI score, which represents overall gait pathology, consistently improved throughout the follow-up duration (1.2 per year, p = 0.008).

CONCLUSION

Medial hamstring lengthening with semitendinosus transfer, as a part of a SEMLS, was effective procedure in treating flexed knee gait with regard to sagittal knee kinematics and GDI score in spastic CP with flexed knee gait.

Femoral derotation osteotomy in adults with cerebral palsy

BACKGROUND

Internal rotation gait constitutes a complex gait disorder in bilateral spastic cerebral palsy (BSCP) including static torsional and dynamic components resulting in lever arm dysfunction. Although femoral derotation osteotomy (FDO) is a standard procedure to correct increased femoral anteversion in children, unpredictable outcome has been reported. The effect of FDO when it is done as part of single-event multilevel surgery (SEMLS) in adulthood has not been investigated.

METHODS

In this study mid-term data of 63 adults with BSCP and internal rotation gait, undergoing SEMLS including FDO were analyzed pre- and 1.7 years postoperatively by clinical examination and 3D-instrumented gait analysis. All legs were categorized as the more or less involved side to consider asymmetry. The mean hip rotation in stance preoperatively and the intraoperative derotation was correlated with the difference pre- and postoperatively.

RESULTS

The group as a whole experienced the following results postoperatively: improved mean hip rotation in stance (p=0.0001), mean foot progression angle (p=0.0001) and a significant improvement of the clinical parameter: passive internal and external hip rotation, midpoint and anteversion (p=0.0001) for both legs separately. With regard to the less and more involved side, clinical and kinematic parameters showed comparable significant changes (p=0.0001). The anteversion improved significantly in proximal compared to distal FDO (p=0.03).

CONCLUSION

This study emphasizes an overall good correction of internal rotation gait in adults with bilateral involvement after FDO. However, the results are more predictable in adults compared to studies reporting outcome after FDO in children.

Multilevel surgery in adults with cerebral palsy

Aims

Single-event multilevel surgery (SEMLS) has been used as an effective intervention in children with bilateral spastic cerebral palsy (BSCP) for 30 years. To date there is no evidence for SEMLS in adults with BSCP and the intervention remains focus of debate.

Methods

This study analysed the short-term outcome (mean 1.7 years, standard deviation 0.9) of 97 ambulatory adults with BSCP who performed three-dimensional gait analysis before and after SEMLS at one institution.

Results

Two objective gait variables were calculated pre- and post-operatively; the Gillette Gait Index (GGI) and the Gait Profile Score (GPS). The results were analysed in three groups according to their childhood surgical history (group 1 = no surgery, group 2 = surgery other than SEMLS, group 3 = SEMLS). Improvements in gait were shown by a significant decrease of GPS (p = 0.001). Similar results were obtained for both legs (GGI right side and left side p = 0.01). Furthermore, significant improvements were found in all subgroups although this was less marked in group 3, where patients had undergone previous SEMLS.

Discussion

SEMLS is an effective and safe procedure to improve gait in adults with cerebral palsy. However, a longer rehabilitation period is to be expected than found in children. SEMLS is still effective in adult patients who have undergone previous SEMLS in childhood. Take home message: Single-event multilevel surgery is a safe and effective procedure to improve gait disorders in adults with bilateral spastic cerebral palsy. Cite this article: Bone Joint J 2016;98-B:282–8.

Long-term ambulatory change after lower extremity orthopaedic surgery in children with cerebral palsy: a retrospective review

BACKGROUND

Long-term studies of lower extremity orthopaedic surgery in children with cerebral palsy (CP) tend to focus on gait kinematics and kinetics, with little to no emphasis on gross motor ambulatory function. The current study was undertaken to examine the long-term impact of surgery on ambulatory function in patients with CP enrolled in a government-funded, outpatient therapy program.

METHODS

Retrospective medical record review was conducted of 127 children with CP, Gross Motor Function Classification System (GMFCS) levels I to IV, followed up to 14 years after lower extremity orthopaedic surgery. Data were extracted from medical/operative records and routine physical therapy evaluations performed over the course of follow-up. Functional Mobility Scale (FMS) scores were assigned based on gross motor function information contained in each 6- to 12-month physical therapy evaluation. Data were compared statistically among GMFCS levels.

RESULTS

Average length of follow up was 11.8±4 years. Subjects underwent 0.61±0.43 surgical procedures per person-year in 0.16±0.09 operative sessions per person-year with no differences between GMFCS levels. Subjects at GMFCS level I improved significantly in community (P=0.02) but not household ambulation, reflecting the ceiling effect of the FMS. Subjects at GMFCS levels II to IV showed statistically significant improvements at all distances. Subjects at level III gained more in household than long-distance ambulation (P=0.002). Subjects functioning at GMFCS level II improved by 1 FMS level for household and school distances, and 2 FMS levels for community distances (P<0.02). Subjects at level IV exhibited small ambulatory gains at all distances (P<0.04).

CONCLUSIONS

Significant long-term improvement in functional ambulation is seen after surgery for children at all GMFCS levels. Children with more independence tend to make gains in long-distance ambulation, whereas those who use assistive devices tend to improve more in short-distance ambulation. This information may be useful to clinicians when counseling patients and their families regarding potential for ambulatory improvement after lower extremity orthopaedic surgery.

LEVEL OF EVIDENCE

Level IV: case series.

Application of the Gillette Gait Index, Gait Deviation Index and Gait Profile Score to multiple clinical pediatric populations

Gait indices are now commonly used to assess overall pathology and outcomes from studies with instrumented gait analyses. There are differences in how these indices are calculated and therefore inherent differences in their sensitivities to detect changes or differences between groups. The purpose of the current study was to examine the three most commonly used gait indices, Gillette Gait Index (GGI), Gait Deviation Index (GDI), and Gait Profile Score (GPS), comparing the statistical sensitivity and the ability to make meaningful interpretations of the clinical results. In addition, the GDI*, a log transformed and scaled version of the GPS score which closely matches the GDI was examined. For seven previous or ongoing studies representing varying gait pathologies seen in clinical laboratories, the GGI, GDI, and GPS/GDI* were calculated retrospectively. The GDI and GPS/GDI* proved to be the most sensitive measures in assessing differences pre/post-treatment or from a control population. A power analysis revealed the GDI and GDI* to be the most sensitive statistical measures (lowest sample sizes required). Subjectively, the GDI and GDI* interpretation seemed to be the most intuitive measure for assessing clinical changes. However, the gait variable sub-scores of the GPS determined several statistical differences which were not previously noted and was the only index tool for quantifying the relative contributions of specific joints or planes of motion. The GGI did not offer any advantages over the other two indices.

Does single-event multilevel surgery enhance physical functioning in the real-life environment in children and adolescents with cerebral palsy (CP)?: patient perceptions five years after surgery

Orthopedic procedures are a method of treating gait deviations and musculoskeletal pathology that develop with age in cerebral palsy (CP). Recently single-event multilevel surgery (SEMLS) has become common practice. Although there is evidence that SEMLS could improve gait, it is unclear whether it will enhance overall physical functioning and coping strategies in the real-life environment. It is unclear how improved walking capacity affects actual functioning and enables greater independence. The aim of this study was to examine the perceptions of adolescents concerning the results of surgery on personal physical functioning in the environment five or more years after SEMLS. In this study, qualitative data were gathered by open interviews and analyzed using phenomenographic approach, which aims to study variation in human understanding and perceptions of the phenomenon in question. Gait Profile Score (GPS) was used to describe the objective change. The results indicate that SEMLS had a clear positive effect on the participants' physical functioning capacity, particularly experienced as better walking ability. GPS improved by 3.5° five years postoperatively. Surgery could enhance physical activity and the motivation to maintain mobility in the future. The perceptions of the effect of surgery on physical functioning in the real-life environment varied from a challenge-avoiding, support-seeking agency to a highly active, independent agency in daily life. Our rehabilitation practice after multilevel surgery should be more focused on enhancing active agency in collaboration with adolescents with CP and their families.

Pes planovalgus deformity in children with cerebral palsy: review article

Pes planovalgus deformity is common in children with cerebral palsy. In planovalgus foot, the talus subluxates medially, the calcaneus is in valgus, and the forefoot is in supination and external rotation related to the midfoot. In young children, mild planovalgus feet can be managed with orthotics. Surgery is indicated if the deformity is not reducible or if the patient cannot tolerate orthotics during functional activities. The surgery can be calcaneal lengthening or subtalar fusion to restore a stable plantigrade foot and achieve hindfoot correction. Medial column fusion is important to reconstruct the medial arch in severe planovalgus feet.

Effects of gastrocnemius fascia lengthening on gait pattern in children with cerebral palsy using the gait profile score

The aim of the present study was to investigate the efficacy of the GPS regarding the quantification of changes in gait following the gastrocnemius fascia lengthening in children with CP. Nineteen children with CP were selected and evaluated in the preoperative period (PRE session) and approximately one year postoperatively (POST session; mean 13.1 ± 5.1 months) using 3D gait analysis and computing the GPS and GVSs. As the GPS represents the difference between the patient's data and the average from the reference dataset, the higher the value of GPS is, more compromised gait of the subject. A statistically significant improvement in mean GPS was found in the POST session (PRE: 13.38 ± 5°; POST: 10.26 ± 2.41°; p<0.05), with an improvement close to 23%. Moreover, the GVSs demonstrated statistically significant improvements in ankle dorsi-plantarflexion (PRE: 22.20 ± 16.36°; POST: 11.50 ± 6.57°; p<0.05) and pelvic rotation (PRE: 9.53 ± 3.87°; POST: 6.47 ± 2.98°; p<0.05). A strong correlation (r=0.75; p<0.05) was found between the preoperative GPS and the percentage of GPS improvement. The results demonstrated that the gastrocnemius fascia lengthening produced a global gait pattern improvement, as showed by the GPS value, which decreased after surgery. Besides this, the GVS permitted to better evidence the joints more compromised by the pathology and their improvement due to the surgery, in this case not only the GVS of the ankle joint but also of the pelvis were characterized by higher GVS values.

Quality of life in youngsters with cerebral palsy after single-event multilevel surgery

A single event-multilevel surgery (SEMLS) is today a well-established modality of treatment in children with cerebral palsy (CP). It comprises muscle lengthening/transfers and correction of bony deformities in a single surgical session. Functional improvements after SEMLS have been examined thoroughly, however little is known about the impact of SEMLS on the quality of life (QOL) of children with CP. This study reports on the QOL of children/adolescents with CP after SEMLS. Forty patients underwent SEMLS and were classified according GMFCS levels II-V, age and time span between surgery and questioning. The Cerebral Palsy Quality of Life Questionnaire for Children (CP QOL-Child) and an author developed questionnaire were completed to evaluate QOL. Overall, children/adolescents reported high quality of life scores after SEMLS on the CP QOL-Child. For all the domains of the CP QOL-Child the children reported significant higher scores than their parents (p < 0.05). Significant differences (p < 0.05) were found for the functional-related domains of the CP QOL-Child between GMFCS level III and levels IV-V, but not for the socio-emotional domains. Older children at the moment of surgery (15y0m-18y11m) reported significantly less 'pain and feeling about disability' than children who were younger when operated on (10y0m-14y11m). Almost all aspects included in the author developed questionnaire improved for the majority of the children after SEMLS.

CONCLUSION

After SEMLS, children with CP report high quality of life, significantly higher than their parents perceived. Function and age may influence specific aspects of QOL after SEMLS.

Explaining the variability improvements in gait quality as a result of single event multi-level surgery in cerebral palsy

PURPOSE

This is a study of all children with spastic diplegic cerebral palsy (Gross Motor Classification System levels II and III) who had single event multi-level surgery (SEMLS) at a single tertiary referral hospital between 1995 and 2008 to identify factors predicting improvement in gait quality as quantified by the gait profile score (GPS). 9 factors (5 dichotomous and 4 continuous, including preoperative GPS) that might be expected to predict outcomes were identified and univariate and multivariable analysis used to explore how these affected outcomes.

SCOPE

Data from 121 children were included. The mean improvement in GPS of 4.3° was 2.7 times the minimal clinically important difference. Univariate analysis suggested that preoperative GPS is a very strong predictor of improvement in GPS (p<10(-5)) and when this is considered as a covariate only GMFCS level (p=10(-5)) and having had previous surgery (p=0.026) were found to be statistically significant predictors of GPS improvement (p<0.05). Children of GMFCS level II improved on average by 2° more than those of level III once differences in preoperative GPS had been accounted for.

CONCLUSION

Children with the most abnormal gait patterns preoperatively, and hence those with the most potential to improve are those that improve the most and surgery has clearly been beneficial. Over a quarter of children show changes in GPS which were less than the MCID. The majority of these were those with the least abnormal gait patterns preoperatively and further research is required to establish whether and how such children benefit from SEMLS.

Gait function and decline in adults with cerebral palsy: a systematic review

PURPOSE

The aim of this systematic review was to identify, appraise and synthesize the evidence describing gait decline in adults with cerebral palsy (CP).

METHOD

Comprehensive searches were conducted in MEDLINE (1970-), EMBASE (1980-), CINAHL (1982-) and AMED (1985-) databases to June 2012. Two reviewers independently completed data extraction and analysis using a modified version of the Downs and Black quality tool.

RESULTS

From the 485 papers identified, 16 met the inclusion criteria. Most studies used samples of convenience. The reported mean ages of the study groups varied from 22 to 42.6 years. Decline in gait function was measured variably with the period of decline undefined or from an unknown reference time during childhood. Results suggest that mobility decline occurs in 25% or more of adults with CP. Those at higher risk of gait decline are those with worse initial gait ability, bilateral rather than unilateral motor impairment, older age and higher levels of pain or fatigue.

CONCLUSION

Many ambulant adults with CP experience mobility decline earlier than their nondisabled peers. More information regarding the natural history of mobility change over the lifespan in adults with CP augmented with self-efficacy qualitative data is needed to direct health advice and appropriate interventions for this group.

IMPLICATIONS FOR REHABILITATION

The literature suggests 25% or more of ambulant adults with cerebral palsy experience gait decline. Higher risk of gait decline occurs in those who are older, less independent in gait, have bilateral motor impairment and higher levels of pain or fatigue. Use of standardized gait measurement tools augmented with self-efficacy measures will aid provision of health advice and interventions.

Long term outcome of single event multilevel surgery in spastic diplegia with flexed knee gait

Distal hamstring lengthening (DHL) is a commonly performed procedure in flexed knee gait. However, the necessity of this procedure has been challenged due to the concerns on adverse effects in long-term follow-up. This retrospective study was undertaken to investigate the long-term outcome of single event multilevel surgery (SEMLS), including bilateral DHL, in ambulatory patients with cerebral palsy using 3D gait analysis. Twenty-nine ambulatory patients with spastic diplegic cerebral palsy who had undergone SEMLS including bilateral DHL were included. 3D gait analysis was performed preoperatively, 1 year postoperatively and over 10 years postoperatively. Preoperative temporal parameters, kinematics and GDI were compared with values obtained 1 and 10 year follow-up visits. The mean age of patients at time of first surgery was 8.3 years (range, 5.4-16.3 years), and mean time from first surgery to last 3D gait analysis was 11.8 years (range, 10.0-13.3 years). Mean pelvic tilt was not changed significantly after SEMLS including DHL. Mean knee flexion at initial contact decreased from 31.1° preoperatively to 26.0° at 1 year postoperatively (p=0.065), and then decreased significantly to 23.6° at 10 years postoperatively (p=0.038) versus the preoperative value. Mean GDI score significantly improved from 69.4 preoperatively to 77.9 at 1 year postoperatively (p=0.003) and continuously improved to 82.2 at 10 years postoperatively (p=0.017). Single event multilevel surgery including DHL provides a favorable outcome 10 years postoperatively in patients with spastic diplegic cerebral palsy.

Gait and participation outcomes in adults with cerebral palsy: a series of case studies using mixed methods

BACKGROUND

There is a paucity of information on long-term outcomes of adults with cerebral palsy (CP) who received orthopedic interventions in childhood. Clinical effectiveness research requires assessment of outcomes that account for personal and environmental factors that may mediate the effects of treatment, in addition to body structures & function, activity, and participation.

OBJECTIVE/HYPOTHESIS

The purpose of this study is to provide a descriptive analysis of characteristics associated with gait and participation outcomes in a series of case studies of adults with CP.

METHODS

Participants had follow up gait analysis and clinical evaluation in adulthood and assessment of outcomes with the FIM instrument, the SF-36 Health survey, the Canadian Occupational Performance Measure, and semi-structured questions.

RESULTS

Twenty-two out of 26 participants (mean age = 25 years; GMFCS level I (n = 9); II (n = 3); III (n = 11); IV (n = 3)) maintained or improved childhood gait abilities, with levels of participation in society similar to age matched peers. Higher level of severity and personal choices impacted gait abilities in the four who declined. Majority of participants lost range of motion in hip flexion and knee extension, had pain, reported a fitness program, and increased in weight status. Personal factors and environmental factors played a role in both gait and participation outcomes.

CONCLUSION

Promotion of fitness activities and social advocacy are warranted for adults with CP. Clinical effectiveness research of long-term impact of orthopedic interventions should account for treatment effects on body structures & function, activity, participation, and modifying effects of personal, and environmental factors.

Walking deterioration and gait analysis in adults with spastic bilateral cerebral palsy

Walking deterioration occurs frequently in adults with spastic bilateral cerebral palsy (CP), but their gait characteristics are largely unknown. The study aims were (1) to compare selected gait analysis variables between those reporting and those not reporting walking deterioration, and (2) to characterise the overall gait deviations and classify the gait patterns. Participants (N=16) were recruited from a follow-up study, had spastic bilateral CP, <40 years in 2006, GMFCS levels I-III, and could walk at least 10 m without support. Eight reported walking deterioration (cases) and eight did not (controls). A theoretical framework linking work of walking, fatigue and deterioration in walking was developed. It was hypothesised that higher energy requirements during gait and larger gait deviations would be associated with deterioration in walking. Three-dimensional gait analysis was used to obtain centre of mass work, mechanical joint work, lower limb kinematics, movement analysis profile (MAP), and gait profile scores (GPS). There were no differences between the cases and controls in centre of mass work, joint work, or in the GPS. The largest MAP deviations were seen in sagittal pelvis, hip, and knee angles and foot progression. Crouch and asymmetric gait were common patterns. Walking deterioration could not be explained by these work and kinematic variables. An individual's perception of deterioration in walking is subjective, and may be experienced and interpreted differently across people. Larger, longitudinal studies on the natural history of walking in spastic CP are needed. Qualitative studies on the subjective experiences of walking deterioration are also warranted.

Pes planovalgus deformity surgical correction in ambulatory children with cerebral palsy

PURPOSE

Planovalgus foot deformity is common in diplegic and quadriplegic patients. Surgery is the definitive treatment to restore the alignment of the talus, calcaneus, and navicular bones. We aimed, in the current study, to compare the effectiveness of subtalar fusion and calcaneal lengthening, and to assess the recurrence in ambulatory children with cerebral palsy.

METHODS

This is a retrospective study of 78 patients (138 feet diagnosed with planovalgus deformity) who underwent surgical correction using subtalar fusion or calcaneal lengthening. Range of motion, radiographic indices, kinematic, and pedobarographic data were used to examine the deformity and the outcome of surgery. A repeated measures analysis of variance (ANOVA) was used to test the study hypothesis.

RESULTS

Most of the patients were diplegic (87.2 %) and the mean age at surgery was 11.9 ± 2.9 years (range from 4.7 to 18.3 years), with a mean follow-up of 5 ± 4.4 years (range from 1 to 15.4 years). Sixty-three feet were treated with calcaneal lengthening, while 75 were treated with subtalar fusion. The feet treated with subtalar fusion were more severe preoperatively. However, both surgery groups showed improvement postoperatively. Among 12 cases of recurrence, medial column fusion was the main surgery performed to correct the deformity.

CONCLUSIONS

Surgery is effective in the treatment of planovalgus deformity in ambulatory children with cerebral palsy. Severe and rigid planovalgus feet can be treated effectively with subtalar fusion. Feet with milder deformity show good results, with calcaneal lengthening. Surgery provides good correction in young patients, but there is a higher recurrence rate.

Single-event multilevel surgery for children with cerebral palsy: a systematic review

AIM

To conduct a systematic review of single-event multilevel surgery (SEMLS) for children with cerebral palsy, with the aim of evaluating the quality of the evidence and developing recommendations for future research.

METHOD

The systematic review was conducted using standard search and extraction methods in Medline, EMBASE, CINAHL, and Cochrane electronic databases. For the purposes of this review, SEMLS was defined as two or more soft-tissue or bony surgical procedures at two or more anatomical levels during one operative procedure, requiring only one hospital admission and one period of rehabilitation. Studies were included if: (1) the primary focus was to examine the effect of SEMLS in children with cerebral palsy; (2) the results focused on multiple anatomic levels and reported findings of one or more World Health Organization International Classification of Functioning, Disability and Health (ICF) domains. Studies that focused on a single intervention or level, or on the utility of a specific outcome measure were excluded. Study quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) and the Oxford Centre for Evidence-Based Medicine scale. The review also examined the reporting of surgery, adverse events, and rehabilitation.

RESULTS

Thirty-one studies fulfilled the criteria for inclusion, over the period 1985 to October 2010. The MINORS score for these studies varied from 4 to 19, with marked variation in the quality of reporting. Study quality has improved over recent years. Valid measures of gait and function have been introduced and several of the most recent studies have addressed multiple dimensions of the ICF. A statistical synthesis of the outcome data was not conducted, although a trend towards favourable outcomes in gait was evident. Caution is advised with interpretation owing to the variable study quality. Uncontrolled studies may have resulted in an overestimation of treatment efficacy.

INTERPRETATION

The design and reporting of studies of SEMLS are improving with the development of multidisciplinary teamwork and frameworks such as the ICF. However, the evidence base is limited by the lack of randomized clinical trials, especially when compared with other surgical interventions such as selective dorsal rhizotomy.