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

Can on-line gait training improve clinical practice? Study protocol for feasibility randomised controlled trial of an on-line educational intervention to improve clinician's gait-related decision-making in ambulant children and young people with cerebral palsy

BACKGROUND

Instrumented gait analysis (IGA) is an assessment and research tool with proven impacts on clinical decision-making for the management of ambulant children and young people with cerebral palsy (CYPwCP) but is underused and variably understood by relevant clinicians. Clinicians' difficulties in gaining expertise and confidence in using IGA are multifactorial and related to access for clinical decision-making, limited training opportunities and inability to translate this training into clinical practice.

METHODS

The primary aim of this study is to test the feasibility of an educational intervention to advance clinicians' application of gait analysis in CYPwCP, to inform a definitive trial. The secondary aim is to measure the effect that appropriate IGA training has on physiotherapists' knowledge, skills, confidence and behaviours. This will be a two-arm feasibility randomised controlled trial with an experimental and control group. The 6-week on-line intervention uses a multicomponent approach grounded in behavioural change techniques. A repeated measures design will be adopted, whereby participants will complete outcome measures at baseline, immediately after the intervention and at 4 months. The primary outcome measures (trial feasibility-related outcomes) are recruitment and engagement. The secondary outcome measures (trial research-related outcomes) are knowledge, skills, confidence and practice change. Outcome measures will be collected via online questionnaires and during observed skill assessments. Analysis of data will use descriptive statistics, two-way mixed ANOVA model and qualitative content analysis.

DISCUSSION

This study will determine feasibility of the definitive randomised control trial of educational intervention delivered to advance clinicians' application of gait analysis in CYPwCP. This study offers the shift in emphasis from regarding IGA as a tool to a focus on clinicians' requirements for access, training and a well-defined role to optimise utilisation of IGA. The impact of this should be better engagement with IGA and clinical practice change. This study will contribute to a body of educational research into clinical education of healthcare professionals and IGA training offering insight into high levels of evaluation evidence including clinical behaviour change.

TRIAL REGISTRATION

Protocol has been registered with the Open Science Framework (osf.io/nweq6) in June 2023.

Comparison of outcomes following surgical intervention and inpatient rehabilitation stays in children with cerebral palsy

INTRODUCTION

Literature is limited on functional outcomes in children with cerebral palsy (CP) following surgical procedures and a subsequent inpatient rehabilitation unit (IRU) stay.

OBJECTIVE

To compare functional outcomes and length of stay (LOS) in children with CP following a surgical procedure and IRU stay based on the surgical procedure performed, pattern of involvement, etiology, and Gross Motor Function Classification System (GMFCS) level.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care pediatrics.

PARTICIPANTS

Pediatric patients with CP who underwent one of three surgical procedures followed by an IRU stay.

INTERVENTIONS

Selective dorsal rhizotomy (SDR), single-event multilevel orthopedic surgery (SEMLS), or intrathecal baclofen (ITB) pump implantation and subsequent IRU stay.

MAIN OUTCOME MEASURES

IRU LOS, Functional Independence Measure for Children (WeeFIM) total score, sub-scores, and efficiency.

RESULTS

Children undergoing SDR had a longer LOS (p ≤ .015). Children with spastic diplegia, GMFCS level II, and prematurity-based CP had higher WeeFIM efficiency scores (p ≤ .046, ≤.021, and .034 respectively). Greater changes in WeeFIM™ scores were associated with spastic diplegia, SDR, GMFCS level II, longer LOS, and higher admission scores (p ≤ .045).

CONCLUSIONS

Although statistically and functionally significant improvements in children with CP following surgical interventions and an IRU stay were seen, those with higher WeeFIM change scores tended to have spastic diplegia, to have undergone SDR, GMFCS level II, longer LOS, and higher admission scores.

Distal femoral osteotomy and patellar tendon advancement for the treatment of crouch gait in patients with bilateral spastic cerebral palsy

BACKGROUND

Crouch gait, or flexed knee gait, represents a common gait pattern in patients with spastic bilateral cerebral palsy (CP). Distal femoral extension and/or shortening osteotomy (DFEO/DFSO) and patellar tendon advancement (PTA) can be considered as viable options when knee flexion contractures are involved. Better outcomes have been reported after a combination of both, independently of the presence of knee extensor lag. In this study, we evaluated the clinical and kinematic outcomes of these procedures.

PATIENTS AND METHODS

We reviewed a cohort of 52 limbs (28 patients) who were treated for crouch gait by DFEO/DFSO alone (group 1, n = 15) or DFEO/DFSO + PTA (group 2, n = 37) as a part of single event multilevel surgery (SEMLS). The mean age at surgery was 14 years, and the mean follow-up time was 18 months. The physical examination data and three-dimensional standardized gait analysis were collected and analyzed before the surgery and postoperatively.

RESULTS

Overall knee range of motion improved in all limbs. The knee flexion decreased significantly in both groups at initial, mid, and terminal stance. Hip flexion significantly decreased in mid-stance for limbs in group 2. Both clinical and gait parameters were most improved in limbs who underwent DFEO/DFSO + PTA. Increased pelvic tilt was observed in both groups after surgery.

CONCLUSION

Although DFEO/DFSO alone was successful in correcting knee flexion contractures, PTA has helped to improve knee extensor lag and knee extension during gait.

LEVEL OF EVIDENCE

Therapeutic level IV.

Effect of selective percutaneous myofascial lengthening and functional physiotherapy on walking in children with cerebral palsy: Three-dimensional gait analysis assessment

BACKGROUND

Walking is the most affected motor function in children with cerebral palsy (CP). Orthopaedic surgery is regularly used to improve ambulation in children with CP. Selective Percutaneous Myofascial Lengthening (SPML) is considered the state-of-the art technique for surgical lengthening of spastic/contracted muscles in CP. The purpose of this study was to investigate the effect of combined SPML surgery and postoperative functional physiotherapy on gait function and characteristics of children with spastic cerebral palsy (CP).

METHODS

Twenty-six children with spastic CP, aged 5-7 years, Gross Motor Function Classification System (GMFCS) levels II (n = 6), III (n = 12) and IV (n = 8) participated in a quasi-experimental one-group pretest-posttest study with a 9-month follow-up. The Global Motion Graph Deviation Index (MGDI) (including MGDI sub-indices of each joint in each plane of motion) and spatiotemporal parameters of a three-dimensional kinematic gait analysis were used to assess the gait function and characteristics, respectively.

RESULTS

Nine months following SPML and functional physiotherapy, statistically significant improvements (p < 0.05) were noted in the Global MGDI, the MGDIs of sagittal plane knee and ankle motion analysis graphs, and the four most common spatiotemporal measures of gait: walking velocity, stride length, step length, and cadence.

CONCLUSION

Children with spastic CP seem to gain better overall gait function following SPML procedure and functional physiotherapy, by achieving higher walking velocity, longer stride length and step length, and faster cadence. Further studies with control group and longer follow-up three-dimensional gait analyses are warranted to validate these positive results.

Characterization of environmental factors in children and adolescents with cerebral palsy in Minas Gerais: Participa Minas

OBJECTIVE

To characterize the environmental factors of children and adolescents with Cerebral Palsy (CP) in the state of Minas Gerais (MG), Brazil.

METHODS

This is a cross-sectional study involving 164 caregivers of children/adolescents with CP, aged 1-14 years. The Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System (MACS) were used to classify the participants' functioning, and environmental factors were evaluated by an on-line questionnaire that examined products and technologies, physical environment, services, and systems. A descriptive analysis was performed using percentage and frequency.

RESULTS

Most participants had bilateral CP (66.9%) and 45% of them were spastic. Levels II and V of the GMFCS and MACS were the most frequent. About half (49.4%) used anticonvulsants, 27.4% underwent botulinum toxin application, and 29% went through orthopedic surgery in the lower limbs. Among the participants, 71.3% used orthoses in the lower limbs, and 51.8% used the public health care system. Most had access to physiotherapy (91.5%), but found difficulties to access interventions with other professionals, such as psychologists (28%) and nutritionists (37.8%). The school was the most frequently adapted environment (78%), and had the highest level of structural adaptation (42.7%).

CONCLUSIONS

The results of this study suggest that the barriers to access health services and barriers to the physical environment may impact participation and social inclusion.

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies

Purpose

To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait.

Methods

Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool.

Results

Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = -6.39; 95% confidence interval = [-10.4, -2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = -14.27; 95% confidence interval = [-18.31, -10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = -5.6; 95% confidence interval = [-9.59, -1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation.

Conclusions

Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase.

Level of evidence

Level III, Systematic review of level III studies.

Case report: Intensive rehabilitation program delivered before and after single-event multilevel surgery in a girl with diplegic cerebral palsy

Introduction

Diplegic cerebral palsy (CP) is often associated with musculoskeletal disorders that contribute to worsen walking function. The standard care in these cases is single-event multilevel surgery (SEMLS) followed by rehabilitation. Our aim was to investigate whether a rehabilitation program starting even before SEML could add a benefit with respect to standard postoperative programs considered by previous research.

Methods

From 2 months before to 13 months after SEMLS (except for the first month after surgery), the participant underwent a motor training focused on ROM exercises with tactile and kinaesthetic feedback. Walking performance, walking capacity, and quality-of-life were assessed before and after SEMLS at different follow-up times.

Results

Walking capacity improved 3 months after SEMLS (i.e., earlier than in current literature) and walking performance improved 12 months after SEMLS (instead of simply returning to baseline as previously reported), with a positive impact on quality-of-life.

Conclusions

This case suggests that a rehabilitation program starting even before SEMLS could add benefits over walking function and quality-of-life of children with diplegic CP compared to postoperative programs only.

Self-reported Health-related Quality of Life in Adolescents With Cerebral Palsy

BACKGROUND

Happiness, comfort, and motor function contribute to satisfaction with life for individuals with cerebral palsy (CP). Evidence-based medical care can improve motor function and physical health of youth with CP. Less is known about medical care and its relationship to health-related quality of life (HRQOL) in adolescents and young adults with CP. This study aimed to describe HRQOL among adolescents with CP to examine differences between adolescent (self) and parent (proxy) reports of HRQOL and to explore associations of pain, age, and gross motor function with HRQOL.

METHODS

This is a retrospective study including adolescents with CP classified as Gross Motor Function Classification System levels I to V, ages 11 to 20 years, reading ≥ a fourth-grade level, and who completed the self-reported Pediatric Outcomes Data Collection Instrument (PODCI). Parents completed the PODCI concurrently or within 12 months and scores were compared. In addition, self-reported scores were compared between age bands, across Gross Motor Function Classification System levels, with typically developing youth (TDY), and between youth with/without pain.

RESULTS

PODCI scores from 102 adolescents [59 males; 15.0 (SD: 2.6) years old] were examined. Scores from 50 adolescents and parents were matched. Mean self-reported scores were significantly higher than mean parent-reported scores in 4 domains: upper extremity and physical function ( P =0.018), sports and physical function ( P =0.005), happiness ( P =0.023), and global functioning ( P =0.018). All domains, except Happiness, were significantly < TDY ( P <0.01). The presence of pain was associated with lower scores in all domains ( P <0.05).

CONCLUSION

Examining HRQOL with the PODCI revealed significant limitations in physical function and higher pain in adolescents with CP compared with TDY. Self- and parent-reported PODCI results should be considered separately. Adolescents report higher HRQOL compared with parent proxy. Recognizing and validating the perspectives of youth and their parents presents an opportunity for providers to discuss different points of view with families. Such engagement can help promote self-efficacy in youth with CP as they transition to the responsibility of guiding their own care in adulthood.

LEVEL OF EVIDENCE

III, Retrospective comparative study.

Clinical functional outcome measures for children with cerebral palsy after gait corrective orthopaedic surgery: A scoping review

AIM

To identify the most frequently reported non-instrumented measures of gait, activity, and participation in children with cerebral palsy (CP) after undergoing gait corrective orthopaedic surgery.

METHOD

Four databases were searched from database inception to the 9th December 2021 for studies that evaluated functional outcomes for children with CP under 18 years undergoing gait corrective orthopaedic surgery.

RESULTS

Of 547 citations, 44 publications (n = 3535 participants, n = 1789 males, mean age 10 years 5 months [SD = 3 years 3 months], Gross Motor Function Classification System levels I-III at the time of surgery) were eligible for inclusion. Fourteen different outcome measures were used: one measure of gait, 10 measures of activity, and three measures of participation. Gait was measured with the Edinburgh Visual Gait Scale (EVGS; 4 out of 44). The most common activity and participation measures were the Functional Mobility Scale (FMS; 15 out of 44) and Pediatric Outcomes Data Collection Instrument (11 out of 44) respectively. No studies reported a combination of gait, activity, and participation measures.

INTERPRETATION

The EVGS and FMS should be considered as core outcome measures in gait corrective orthopaedic surgery, while a measure of participation is unclear. Additional considerations for developing a comprehensive suite of outcomes include identifying a combination of clinical measures and performance-reflective questionnaires that are standardized for children with CP undergoing surgery and meaningful to clinicians and families.

Single-Event Multi-Level Surgery in Cerebral Palsy: A Bibliometric Analysis

Background and Objectives: Single-Event Multi-Level Surgery (SEMLS) is a complex surgical programme in which soft tissue contractures and bony torsional deformities at the ankle, knee and hip, in both lower limbs are surgically corrected during a single operative session, requiring one hospital admission and one period of rehabilitation. The aim of SEMLS is to improve gait and function in ambulant children with cerebral palsy. Utilisation of the SEMLS concept can reduce the number of surgical events, hospital inpatient stays and reduce rehabilitation requirements to a single intensive episode. Three-dimensional gait analysis is a pre-requisite to plan intervention at multiple anatomic levels to correct fixed deformities and to improve gait and function. Materials and Methods: This study was a bibliometric analysis of SEMLS in cerebral palsy using the Clarivate Web of Science Core Collection database from 1900 to 29 May 2023. Results: A total of 84 studies met the inclusion criteria. The most highly cited article was "Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery" by Rodda et al. (2006) with 141 citations. The most productive institutions by number of articles were the Royal Children's Hospital Melbourne (Australia), Murdoch Children's Research Institute (Australia) and University of Melbourne (Australia). The most productive author by number of citations was HK Graham (Australia). Conclusions: The literature base for SEMLS consists largely of retrospective cohort studies. The aforementioned three institutes in Melbourne, Australia, which frequently collaborate together, have contributed the greatest number of studies in this field.

Preoperative Biopsychosocial Assessment and Length of Stay in Orthopaedic Surgery Admissions of Youth with Cerebral Palsy

Caregivers of children with cerebral palsy (CP) experience stress surrounding orthopaedic surgery related to their child's pain and recovery needs. Social determinants of health can affect the severity of this stress and hinder health care delivery. A preoperative biopsychosocial assessment (BPSA) can identify risk factors and assist in alleviating psychosocial risk. This study examined the relationship between the completion of a BPSA, hospital length of stay (LOS), and 30-day readmission rates for children with CP who underwent hip reconstruction (HR) or posterior spinal fusion (PSF). Outcomes were compared with a matched group who did not have a preoperative BPSA. The BPSA involved meeting with a social worker to discuss support systems, financial needs, transportation, equipment, housing, and other services. A total of 92 children (28 HR pairs, 18 PSF pairs) were identified. Wilcoxon analysis was statistically significant (p = 0.000228) for shorter LOS in children who underwent PSF with preoperative BPSA (median = 7.0 days) vs. without (median = 12.5 days). Multivariate analysis showed that a BPSA, a lower Gross Motor Function Classification System level, and fewer comorbidities were associated with a shorter LOS after both PSF and HR (p < 0.05). Identifying and addressing the psychosocial needs of patients and caregivers prior to surgery can lead to more timely discharge postoperatively.

A core outcome set for lower limb orthopaedic surgery for children with cerebral palsy: An international multi-stakeholder consensus study

AIM

To develop a core set of outcome domains to be measured in clinical studies on lower limb orthopaedic surgery for ambulant children with cerebral palsy (CP) that represents the priorities of an international multi-stakeholder group (children, parent/carers, and health professionals).

METHOD

Potential outcome domains were identified through literature review and qualitative interviews with key stakeholders. These were scored in an international two-round Delphi survey, using a 9-point Likert scale. A final consensus meeting with key stakeholders agreed on the most important outcome domains and refined the core outcome set (COS).

RESULTS

One hundred and sixty-one health professionals and 36 individuals with CP and their parents/carers rated 21 of 41 outcomes as important in the Delphi survey. The final consensus group agreed 19 outcomes within eight domains to be included in the final COS: pain and fatigue, lower limb structure, motor function, mobility (daily life activities), gait-related outcomes, physical activity, independence, and quality of life.

INTERPRETATION

A COS for lower limb orthopaedic surgery for children with CP was developed. Incorporating this in the design of future clinical studies will provide a more holistic assessment of the impact of treatment while allowing meaningful comparisons and future synthesis of results from primary studies.

WHAT THIS PAPER ADDS

Eight core outcome domains were identified as important to measure in future clinical research. Key stakeholders perceived pain, balance and fall, and independence as very important outcomes. Six contextual factors were identified as essential in surgical decision-making.

Changes in the Status of Spastic Diplegic Children in Terms of Gross Motor Function Classification System and Functional Mobility Scale Following Surgical Intervention: A Single Centre Experience

Introduction Most centers in low- to mid-income countries (LMICs) lack facilities for a comprehensive instrumented gait analysis (IGA) which is often considered the preferred method for assessment of the functional results of surgery in children with spastic diplegia. We aimed to study if there were any changes in the Gross Motor Function Classification System (GMFCS) levels and Functional Mobility Scale (FMS) scores after surgery and whether they can be used as an indirect indicator of change in the functional status of a child. Methods This prospective study was conducted at the Pediatric Orthopedic unit of a teaching hospital on spastic diplegic children requiring surgical intervention. GMFCS levels and FMS scores were recorded before the surgery and at each follow-up visit, with the latest record being two years post-surgery. The change in the scores was indicated as an improvement, deterioration, or no change from the baseline and compared to the score of the preceding visit. In addition, it was examined whether the age at surgery had any effect on the temporal change in the scores. Results A total of 25 children were included for analysis after excluding those who failed to fulfill the predefined inclusion and exclusion criteria. Both the GMFCS levels and FMS scores improved from the third month to one-year post-surgery, after which a few patients had a worsening of their scores at the two years follow-up visit. The age at which surgery was performed had no significant effect on the pattern of change in the scores. Most children sought consultations with the physical therapy department only when they visited the surgical team for follow-up. Conclusion This study shows that surgical interventions do improve the functional outcomes in children with spastic CP when assessed using FMS scores while maintaining an undeteriorated GMFCS level in most children. While a peak improvement can be expected one year after surgery in most patients, possible of worsening from baseline scores do exist, and the parents must be informed of the same. Any decision for surgery must involve the parents, and the usefulness of postoperative physical therapy must be impressed upon them before the surgery and during each follow-up visit too.

Is Standing Function Improved After Orthopaedic Surgery in Children With Cerebral Palsy at GMFCS Levels III/IV?

BACKGROUND

Children with cerebral palsy (CP) at Gross Motor Function Classification System (GMFCS) levels III/IV are at risk for losses in standing function during adolescence and transition to adulthood. Multilevel surgery (MLS) is an effective treatment to improve gait, but its effects on standing function are not well documented. The objectives of our study were to describe standing function in children with CP classified as GMFCS levels III/IV and evaluate change after MLS.

METHODS

This retrospective study included children with CP (GMFCS III/IV) ages 6 to 20 years who underwent instrumented gait analysis. A subset who underwent MLS were evaluated for change. Primary outcome measures were Gross Motor Function Measure dimension D, gait velocity, functional mobility scale, and the Pediatric Outcomes Data Collection Instrument (PODCI). Additional impairment level measures included foot pressure, knee extension during stance phase of gait, and knee extension passive range of motion.

RESULTS

Four hundred thirty-seven instrumented gait analysis sessions from 321 children with CP (ages 13.7±4.8 y; GMFCS III-81%/IV-19%) were included. The GMFCS III group had higher Gross Motor Function Measure dimension D, gait velocity, PODCI scores, and better knee extension compared with the GMFCS IV group ( P <0.05); 94 MLS were evaluated for postoperative change 15.3±4.2 months after MLS. Children at GMFCS level III had improved PODCI scores ( P <0.05), better knee extension passive range of motion ( P <0.01), and improved coronal plane foot pressure ( P <0.05) post MLS. Maximum knee extension during stance and heel impulse improved significantly in both groups ( P <0.01).

CONCLUSIONS

Standing function of children with CP at GMFCS IV was significantly more limited than at GMFCS III. After MLS, both groups (III/IV) showed improvement in impairment level outcomes (knee extension and foot position), whereas only those functioning at GMFCS III had improvement in activity/participation outcomes according to the PODCI. For children with CP at GMFCS levels IV, MLS may improve standing function, but appropriate goals related to assisted standing and measurement protocols sensitive to limited functional mobility should be adopted.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Inpatient Physical Therapy After Orthopedic Lower Extremity Surgery in Children With Cerebral Palsy

PURPOSE

To characterize and examine the variability in receipt of inpatient (IP) physical therapy after lower extremity (LE) orthopedic surgery for individuals with cerebral palsy (CP) across hospital-level (region, bed size) and individual characteristics (gender, age, race/ethnicity, insurance type, technology dependency, and surgical burden).

METHODS

We retrospectively analyzed physical therapy billing data of children with CP who had LE orthopedic surgery from October 1, 2015, through September 30, 2017, from the Pediatric Health Information Services (PHIS) database.

RESULTS

Seventy-five percent of individuals received IP physical therapy during the hospital stay. Individuals from the South and West and those who were technology dependent were less likely to receive IP therapy. Those at large hospitals, aged 11 to 14 years, and with a high surgical burden were more likely to receive therapy.

CONCLUSIONS

Results provide a starting point for future research on the discrepancies of acute physical therapy services in children diagnosed with CP. (Supplemental digital content video abstract available at: http://links.lww.com/PPT/A420).

Factors Associated With Short-Term Recovery Following Single-Event Multilevel Surgery for Children With Cerebral Palsy

PURPOSE

To examine the role of multiple factors, including therapy dose, on recovery of mobility function during post-single-event multilevel surgery (SEMLS) rehabilitation in youth with cerebral palsy.

METHODS

Several factors expected to influence postoperative change in Gross Motor Function Measure (GMFM) were examined: age, Gross Motor Function Classification System (GMFCS) level, cognition, number of osteotomies, surgical complications, medical comorbidities, number of therapy sessions, and preoperative measures of gait, balance, and gross motor function.

RESULTS

Sixty-nine youth with cerebral palsy, GMFSC levels I-IV, who had undergone SEMLS and rehabilitation had on average 2.6 osteotomies and 89 postoperative therapy sessions. Fewer osteotomies, higher therapy dose, higher preoperative GMFM, and lower GMFM at postoperative admission were significant in determining GMFM change.

CONCLUSIONS

The most relevant factors on post-SEMLS recovery were therapy dose, surgical burden, and level of gross motor function immediately before and after surgery.

The effect of medial only versus medial and lateral hamstring lengthening on transverse gait parameters in cerebral palsy

Benefits of hamstring lengthening surgery on the sagittal plane in children with cerebral palsy have been previously demonstrated, but there is limited information on its effects on the transverse plane. This study compared the effects of medial hamstring lengthening (MHL) with those of medial and lateral hamstring lengthening (MLHL) procedures in the transverse plane. Children with gross motor function classification system (GMFCS) levels I-III who had MHL or MLHL were included. Baseline, short- (1-2 years), and long-term (3+ years) postoperative three-dimensional gait analysis outcomes were compared using analysis of variance. Children were excluded if they had concurrent osteotomies or tendon transfers. One hundred fifty children (235 limbs) were included, with 110 limbs in the MHL group (age 8.5 ± 4.1 years, GMFCS I-27%, II-52%, and III-21%) and 125 limbs in the MLHL group (age 10.0 ± 4.0 years, GMFCS I-23%, II-41%, and III-37%). Time between surgery and short- and long-term follow-up gait analysis was 1.5 ± 0.6 years and 6.6 ± 2.9 years, respectively. Transmalleolar axis became more external after MHL at both short and long terms ( P < 0.05), whereas there were only significant differences at long term in MLHL ( P < 0.05). Although hamstring lengthening has a positive impact on stance phase knee extension in children with cerebral palsy, intact lateral hamstrings after MHL likely contribute to increased tibial external rotation after surgery. Significant increases in external rotation at the knee in the long term are likely related to a trend present with growth in children with cerebral palsy rather than a direct result of surgical intervention.

EVALUATION OF TENOTOMY IN THE HIP SUBLUXATION TREATMENT OF CHILDREN WITH ZIKA SYNDROME

Objectives

Evaluate the efficacy and effects of releasing the muscles of subluxated hips of patients with SCZ.

Methods

This is a retrospective study with 29 patients with subluxation of the hip, corresponding to 55 hips operated in a public hospital in Recife, Brazil. Preoperative femoral head migration (PM) percentages were evaluated and compared with 6- and 12-month postoperative results.

Results

Twenty-nine patients were eligible, representing 55 hips evaluated. 19 were female (65.5%), with a mean age of 31.45 months (ranging from 23 to 42 years). 19 patients were GMFCS level V (65.5%), 34.5% were level IV, and 20 of the 29 patients (69%) had no complications. The PM had an absolute reduction of 11.6% (GMFCS IV) and 13.31% (GMFCS V) in the first six months. After 12 months, there was a regression of MP of 7.14% (GMFCS V) and 11.25% (GMFCS IV) compared to preoperative values, with no significant statistical difference among MP values presented between 6 and 12 months after surgery.

Conclusions

The surgery was effective in PM regression during the analyzed period and presented a low complication rate. Level of Evidence III; Comparative retrospective study.

Short-Term Outcome of Rehabilitation Program with Hybrid Assistive Limb after Tendon Lengthening in Patients with Cerebral Palsy

In this study, we aimed to evaluate the short-term outcomes of a rehabilitation program with the Hybrid Assistive Limb® after soft tissue lengthening in young patients with cerebral palsy. We assessed six patients with cerebral palsy who underwent soft tissue surgery followed by gait training using the Hybrid Assistive Limb®. Clinical assessments were conducted preoperatively, before, immediately after, and at 1, 2, and 3 months after gait training. Gross Motor Function Measure was improved 5.93 ± 6.11% (mean ± standard deviation, p < 0.05), Canadian Occupational Performance Measure performance was improved 3.12 ± 1.53 points, and satisfaction was improved 3.80 ± 2.14 points (p < 0.05). The knee extension strength on the operated side was changed 7.75 ± 4.97 Nm after the intervention (p = 0.07). In ambulatory patients, gait speed was changed 8.37 ± 1.72 m/min, stride length was changed 10 ± 6.16 cm, and 6 min walking distance was changed 52 ± 16 m after the intervention. Training with the Hybrid Assistive Limb® may improve walking ability and clinical outcomes in young patients with cerebral palsy after soft tissue lengthening.

Effect of an augmented reality active video game for gait training in children with cerebral palsy following single-event multilevel surgery: protocol for a randomised controlled trial

INTRODUCTION

In paediatric rehabilitation, fun and motivation are also critical keys to successful therapy. A variety of interventions have shown positive effects, high level of interest, compliance and engagement with active video game (AVG).This seems to be an interesting approach for the postoperative gait rehabilitation of children with cerebral palsy (CP). In this study, we will investigate if an overground gait training (GT) delivered through an AVG can improve walking capacity and anaerobic performance.

METHODS AND ANALYSIS

This study is a randomised clinical controlled trial. A total of 14 children and adolescents in the age of 10-18 years with CP will be included. The minimum time between surgery and inclusion will be 7 weeks. The test group will participate in the GT programme with Augmented Reality Rehabilitation of Walking-Cerebral Palsy AVG, control group will receive GT on a treadmill. The primary outcome is the 6-Min Walk Test assessing walking capacity; secondary outcomes are the Muscle Power Sprint Test for anaerobic performance and Shuttle Run Test for physical fitness level. Satisfaction is tested with the Physical Activity Enjoyment Scale.

ETHICS AND DISSEMINATION

The findings will be disseminated by publications in peer-reviewed journals and conferences. This study received agreement from French ethic committee (Comité de Protection des Personnes Sud-Est VI-Number 2020-A02959-30).

TRIAL REGISTRATION NUMBER

NCT04837105.

Walking activity after multilevel orthopedic surgery in children with cerebral palsy

AIM

To determine how surgical burden and preoperative factors affect the recovery of walking activity after multilevel orthopedic surgery (MLS).

METHOD

In this retrospective study, inclusion criteria were a diagnosis of cerebral palsy, MLS, and walking activity monitoring using a StepWatch device within 12 months pre-MLS and 24 months post-MLS. The outcome measure was total mean strides per day normalized to age and Gross Motor Function Classification System level. Pre- and postoperative walking activity were compared using unpaired t-tests; the effects of preoperative predictors and surgical burden on the recovery of walking activity were evaluated using regression analysis.

RESULTS

Participants included 178 children (mean age 12 years 10 months [SD 8 years 7 months; range 4-20 years]; 91 males, 87 females). On average, children returned to baseline walking activity 3 months after low-burden surgery and 1 year 2 months after high-burden surgery. Postoperative walking activity was higher for children who had surgery at a younger age and those with a higher preoperative mobility function.

INTERPRETATION

The burden of MLS was found to be inversely related to the time to recovery of postoperative walking activity. These findings provide evidence to help clinicians set expectations for return to function post-MLS. Further study is necessary to investigate the impact of postoperative factors on walking activity recovery.

WHAT THIS PAPER ADDS

High-burden surgeries lead to longer recovery than low-burden surgeries. Younger children recover walking activity faster after multilevel orthopedic surgery. Children with high preoperative mobility function recover walking activity faster after surgery.

Long-term follow-up after multilevel surgery in cerebral palsy

INTRODUCTION

Single-event multilevel surgery (SEMLS) is frequently used to correct pathological gait patterns in children with bilateral spastic cerebral palsy (BSCP) in a single session surgery. However, in-depth long-term evaluation reports of gait outcomes are limited. Therefore, we investigated if SEMLS is able to correct lower extremity joint and pelvic angles during gait towards typically developing gait patterns (TDC) in children with BSCP, and if so, if this effect is durable over a 10-year period.

MATERIALS AND METHODS

In total 13 children with BSCP GMFCS level II at time of index-surgery between the ages of 7.7-18.2 years at the time of SEMLS were retrospectively recruited. Three-dimensional gait data were captured preoperatively, as well as at short-, mid-, and long-term post-operatively, and used to analyze: movement analysis profile (MAP), gait profile score (GPS), and lower extremity joint and pelvic angles over the course of a gait cycle using statistical parametric mapping.

RESULTS

In agreement with previous studies, MAP and GPS improved towards TDCs after surgery, as did knee extension during the stance phase (ɳ² = 0.67; p < 0.001), while knee flexion in the swing phase (ɳ² = 0.67; p < 0.001) and pelvic tilt over the complete gait cycle (ɳ² = 0.36; p < 0.001) deteriorated; no differences were observed between follow-ups. However, further surgical interventions were required in 8 out of 13 of the participants to maintain improvements 10 years post-surgery.

CONCLUSIONS

While the overall gait pattern improved, our results showed specific aspects of the gait cycle actually deteriorated post-SEMLS and that a majority of the participants needed additional surgery, supporting previous statements for the use of multilevel surgery rather than SEMLS. The results highlight that the field should not only focus on the overall gait scores when evaluating treatment outcomes but should offer additional long-term follow-up of lower extremity function.

Assessment of 30-Day Adverse Events in Single-Event, Multilevel Upper Extremity Surgery in Adult Patients with Upper Motor Neuron Syndrome

BACKGROUND

Upper motor neuron (UMN) syndrome consists of muscle spasticity, weakness, and dyssynergy due to a brain or spinal cord injury. The purpose of this study is to describe the perioperative adverse events for adult patients undergoing single-event, multilevel upper extremity surgery (SEMLS) due to UMN syndrome.

METHODS

A retrospective case series was performed for 12 consecutive adult patients who underwent SEMLS to correct upper extremity dysfunction or deformity secondary to UMN syndrome. The evaluation consisted of primary outcome measures to identify readmission rates and classify adverse events that occurred within 30 days after surgery.

RESULTS

All 12 patients were functionally dependent with 50% (n = 6) men and 50% (n = 6) women at a mean age of 43.6 years (range: 21-73) with a mean of 5.92 (range: 0-16) comorbid diagnoses at the time of surgery. There were no intraoperative complications, hospital readmissions, or deaths among the 12 patients. Five patients experienced 5 minor postoperative complications that consisted of cast- or orthosis-related skin breakdown remote from the incision (n = 3), incidental surgical site hematoma that required no surveillance or intervention (n = 1), and contact dermatitis attributed to the surgical dressing that resolved with topical corticosteroids (n = 1).

CONCLUSIONS

With an appropriate multidisciplinary approach, there is minimal risk for developing perioperative and 30-day postoperative adverse events for adults undergoing SEMLS to correct upper extremity deformities secondary to UMN syndrome.

LEVEL OF EVIDENCE

Level IV.

Interventions with an Impact on Cognitive Functions in Cerebral Palsy: a Systematic Review

This systematic review aimed at investigating those interventions that impact on cognitive functioning in children and adults with cerebral palsy (CP). A systematic database search was conducted and twenty-eight studies suitable for inclusion were identified, of which only nine were randomized controlled trials (RCTs). Among all the studies included, ten were multi-modal (cognitive and physical tasks), eleven physical, five cognitive, and two alternative and augmentative communication interventions. The evidence suggests that multi-modal and physical interventions improve general cognitive functioning. Multi-modal and cognitive interventions have an impact on visual perception. Both interventions, together with physical interventions have an effect on a specific executive function domain (inhibitory control), and only cognitive interventions improved other executive function domains such as working memory. However, no RCT assessed the effects of all executive function domains. Few studies have looked at interventions to improve memory and language, and there is a scarcity of long-term research. Future RCTs must be of higher quality and better account for age and sex differences, as well as the clinical heterogeneity of CP. To date, there is evidence that multi-modal, cognitive or physical interventions have an impact on general cognitive functioning, visual perception and executive functions in children with CP, which may support their cognitive development.The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO): CRD42020152616.

Management of arthrofibrosis in neuromuscular disorders: a review

Arthrofibrosis, or rigid contracture of major articular joints, is a significant morbidity of many neurodegenerative disorders. The pathogenesis depends on the mechanism and severity of the precipitating neuromuscular disorder. Most neuromuscular disorders, whether spastic or hypotonic, culminate in decreased joint range of motion. Limited range of motion precipitates a cascade of pathophysiological changes in the muscle-tendon unit, the joint capsule, and the articular cartilage. Resulting joint contractures limit functional mobility, posing both physical and psychosocial burdens to patients, economic burdens on the healthcare system, and lost productivity to society. This article reviews the pathophysiology of arthrofibrosis in the setting of neuromuscular disorders. We describe current non-surgical and surgical interventions for treating arthrofibrosis of commonly affected joints. In addition, we preview several promising modalities under development to ameliorate arthrofibrosis non-surgically and discuss limitations in the field of arthrofibrosis secondary to neuromuscular disorders.

Causal factors affecting gross motor function in children diagnosed with cerebral palsy

Background

Cerebral palsy (CP) is a complex neuromuscular condition that may negatively influence gross motor function. Children diagnosed with CP often exhibit spasticity, weakness, reduced motor control, contracture, and bony malalignment. Despite many previous association studies, the causal impact of these impairments on motor function is unknown.

Aim

In this study, we proposed a causal model which estimated the effects of common impairments on motor function in children with spastic CP as measured by the 66-item Gross Motor Function Measure (GMFM-66). We estimated both direct and total effect sizes of all included variables using linear regression based on covariate adjustment sets implied by the minimally sufficient adjustment sets. In addition, we estimated bivariate effect sizes of all measures for comparison.

Method

We retrospectively evaluated 300 consecutive subjects with spastic cerebral palsy who underwent routine clinical gait analysis. Model data included standard information collected during this analysis.

Results

The largest causal effect sizes, as measured by standardized regression coefficients, were found for selective voluntary motor control and dynamic motor control, followed by strength, then gait deviations. In contrast, common treatment targets, such as spasticity and orthopedic deformity, had relatively small effects. Effect sizes estimated from bivariate models, which cannot appropriately adjust for other causal factors, substantially overestimated the total effect of spasticity, strength, and orthopedic deformity.

Interpretation

Understanding the effects of impairments on gross motor function will allow clinicians to direct treatments at those impairments with the greatest potential to influence gross motor function and provide realistic expectations of the anticipated changes.

Altered Muscle Contributions are Required to Support the Stance Limb During Voluntary Toe-Walking

Toe-walking characterizes several neuromuscular conditions and is associated with a reduction in gait stability and efficiency, as well as in life quality. The optimal choice of treatment depends on a correct understanding of the underlying pathology and on the individual biomechanics of walking. The objective of this study was to describe gait deviations occurring in a cohort of healthy adult subjects when mimicking a unilateral toe-walking pattern compared to their normal heel-to-toe gait pattern. The focus was to characterize the functional adaptations of the major lower-limb muscles which are required in order to toe walk. Musculoskeletal modeling was used to estimate the required muscle contributions to the joint sagittal moments. The support moment, defined as the sum of the sagittal extensive moments at the ankle, knee, and hip joints, was used to evaluate the overall muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Compared to a normal heel-to-toe gait pattern, toe-walking was characterized by significantly different lower-limb kinematics and kinetics. The altered kinetic demands at each joint translated into different necessary moment contributions from most muscles. In particular, an earlier and prolonged ankle plantarflexion contribution was required from the soleus and gastrocnemius during most of the stance phase. The hip extensors had to provide a higher extensive moment during loading response, while a significantly higher knee extension contribution from the vasti was necessary during mid-stance. Compensatory muscular activations are therefore functionally required at every joint level in order to toe walk. A higher support moment during toe-walking indicates an overall higher muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Higher muscular demands during gait may lead to fatigue, pain, and reduced quality of life. Toe-walking is indeed associated with significantly larger muscle forces exerted by the quadriceps to the patella and prolonged force transmission through the Achilles tendon during stance phase. Optimal treatment options should therefore account for muscular demands and potential overloads associated with specific compensatory mechanisms.

Rehabilitation After Single-Event Multilevel Surgery for Children and Young Adults With Cerebral Palsy: A Systematic Review

ABSTRACT

This review sought to describe and analyze published protocols for rehabilitation after single-event multilevel surgery for people with cerebral palsy, to identify their differences and limits, and to introduce a common step-by-step framework for future descriptions and assessments of postoperative rehabilitation protocols.The MEDLINE, Embase, CINAHL, and the Cochrane Library databases were searched. Inclusion criteria were as follows: (1) single-event multilevel surgery, (2) full-text reports published after 1985, and (3) articles with a method section describing the rehabilitation protocol. Interventions were coded using the Oxford Levels of Evidence and the Methodological Index for Non-Randomized Studies Index.Twenty-four articles were included in the review. Studies included patients aged 4-30 yrs with spastic cerebral palsy (hemiplegia, diplegia, and quadriplegia). The mean postoperative rehabilitation duration was 4.5 mos, with 4 sessions per week, and rehabilitation took place in a rehabilitation center. This review provides relevant information about the modalities, contents, limits, and difficulties associated with the post-SEMS rehabilitation protocol reported in the literature. Pain was identified as a major problem.A more precise and comprehensive description of post-SEMS rehabilitation protocols would be useful. The proposed five-step framework could be used by future studies to standardize their protocol description in terms of objective, content, and intensity.

Tranexamic acid use decreases transfusion rate in children with cerebral palsy undergoing proximal femoral varus derotational osteotomy

Previous studies demonstrated the safety of tranexamic acid (TXA) use in cerebral palsy (CP) patients undergoing proximal femoral varus derotational osteotomy (VDRO), but were underpowered to determine if TXA alters transfusion rates or estimated blood loss (EBL). The purpose of this study was to investigate if intraoperative TXA administration alters transfusion rates or EBL in patients with CP undergoing VDRO surgery.We conducted a retrospective review of 390 patients with CP who underwent VDRO surgery between January 2004 and August 2019 at a single institution. Patients without sufficient clinical data and patients with preexisting bleeding or coagulation disorders were excluded. Patients were divided into 2 groups: those who received intraoperative TXA and those who did not.Out of 390 patients (mean age 9.4 ± 3.8 years), 80 received intravenous TXA (TXA group) and 310 did not (No-TXA group). There was no difference in mean weight at surgery (P = .25), Gross Motor Function Classification System level (P = .99), American Society of Anesthesiologist classification (P = .50), preoperative feeding status (P = .16), operative time (P = .91), or number of procedures performed (P = .12) between the groups. The overall transfusion rate was lower in the TXA group (13.8%; 11/80) than the No-TXA group (25.2%; 78/310) (P = .04), as was the postoperative transfusion rate (7.5%; 6/80 in the TXA group vs 18.4%; 57/310 in the No-TXA group) (P = .02). The intraoperative transfusion rate was similar for the 2 groups (TXA: 7.5%; 6/80 vs No-TXA: 10.3%; 32/310; P = .53). The EBL was slightly lower in the TXA group, although this was not significant (TXA: 142.9 ± 113.1 mL vs No-TXA: 177.4 ± 169.1 mL; P = .09). The standard deviation for EBL was greater in the No-TXA group due to more high EBL outliers. The percentage of blood loss based on weight was similar between the groups (TXA: 9.2% vs No-TXA: 10.1%; P = .40). The number needed to treat (NNT) with TXA to avoid one peri-operative blood transfusion in this series was 9.The use of intraoperative TXA in patients with CP undergoing VDRO surgery lowers overall and postoperative transfusion rates.Level of evidence: III, Retrospective Comparative Study.

Relationship between ankle function and walking ability for children and young adults with cerebral palsy: A systematic review of deficits and targeted interventions

BACKGROUND

A primary goal of treatment for children with cerebral palsy is improved walking ability to allow for a more active and independent lifestyle. With the importance of ankle function to walking ability, and the deficits in ankle function associated with cerebral palsy, there is good rationale for targeting this joint in an effort to improve walking ability for this population.

RESEARCH QUESTION

How do deficits and targeted interventions of the ankle joint influence walking ability in children with cerebral palsy?

METHODS

A specific search criteria was used to identify articles that either (1) provided information on the relationship between ankle function and walking ability or (2) investigated the effect of a targeted ankle intervention on walking ability in cerebral palsy. PubMed, Embase, CINAHL, and Web of Science databases were searched from 1980-April, 2020. Resulting citations were compared against a prospective set of inclusion and exclusion criteria. Data relevant to the original research question was extracted, and the level of evidence for each intervention study was scored. Interpretation was focused on specific, pre-determined mobility measures.

RESULTS

Sixty-one citations met all criteria for data extraction, six of which were observational, and fifty-five of which were interventional. Level of evidence ranged from 2 to 4. Self-selected walking speed was the most common measure of walking ability, while physical activity level was the least common.

SIGNIFICANCE

Ankle function is an important contributor to the walking ability of children with cerebral palsy, and most interventions targeting the ankle seem to demonstrate a benefit on walking ability, but future higher-powered and/or controlled studies are necessary to confirm these findings.

Neuromuscular Electrical Stimulation to Immobilized Lower Extremities Directly Following Orthopaedic Surgery in Three Children with Cerebral Palsy: A Case Series

Cerebral palsy (CP) is a non-progressive, neurological disorder often resulting in secondary musculoskeletal impairments affecting alignment and function which can result in orthopaedic surgery. Neuromuscular electrical stimulation (NMES) is a modality that can be used for rehabilitation; however, NMES immediately following orthopaedic surgery in children with CP using surface electrodes has not been previously reported. The purpose of this case series is to describe the novel use of NMES in the acute rehabilitation phase directly after orthopaedic surgery. This case series included three children with spastic diplegia CP, Gross Motor Function Classification System level II who underwent Single Event Multi-Level orthopaedic Surgery. Each long leg cast contained window cast cut-outs to allow for surface electrode placement for daily NMES intervention to the quadriceps muscles while immobilized. Children were assessed pre- and post-operatively using the Functional Mobility Scale (FMS), Gross Motor Function Measure (GMFM-66), and 6-Minute Walk Test (6MWT). All children demonstrated no adverse effects using NMES intervention and had improvements in the 6MWT. Most children demonstrated gains in the FMS and GMFM-66. Use of NMES through window cast-cuts in a long leg cast is a novel practice approach for delivery of early rehabilitation following lower extremity orthopaedic surgery.

Effects of minimally invasive surgery and functional physiotherapy on motor function of children with cerebral palsy: A non-randomised controlled trial

Purpose

This non-randomised controlled trial investigated whether a combined programme of functional physiotherapy and minimally invasive orthopaedic surgery improves the level and degree of capacity and performance of gross motor function in children with spastic cerebral palsy (CP).

Methods

Fifty-two children with spastic CP aged 5-7 years, Gross Motor Function Classification System (GMFCS) levels II-IV, were allocated to two equal groups: experimental group (selective percutaneous myofascial lengthening [SPML] procedure and 9-month functional strengthening physiotherapy programme) and control (standard physiotherapy) groups. At baseline and at the end of the 9-month intervention, the capacity and performance of gross motor function were assessed with the Gross Motor Function Measure (GMFM) D and E subcategories and Functional Mobility Scale (FMS), respectively. The level of gross motor function was measured with the GMFCS.

Results

There was a statistically significant difference in the post-intervention improvements in the GMFM D (experimental mean difference = 19.63 ± 10.46; control mean difference = 2.40 ± 4.62) and E (experimental mean difference = 19.33 ± 11.82; control mean difference = 4.20 ± 6.26) between experimental and control group (p < 0.001). There was a significant improvement in the GMFCS level and each FMS distance for the experimental group (p < 0.001), but not for the control group (p > 0.05).

Conclusion

SPML procedure combined with functional physiotherapy improves gross motor function in children with spastic CP, by raising the degree and level of motor independence.

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.

Biomechanical assessment of patellar tendon advancement in patients with cerebral palsy and crouch gait

BACKGROUND

Patellar height is a valuable measure to evaluate the effect of patellar tendon advancement (PTA) on knee function. In the literature, there is no validated procedure to measure the patellar height. In this study we aimed to (1) determine the patella position through musculoskeletal modeling, (2) investigate the effects of two surgical procedures applied for PTA, and (3) assess the effect of PTA in combination with single-event multilevel surgery (SEMLS) on the knee kinematics of patients with cerebral palsy (CP) and crouch gait.

METHOD

Three-dimensional gait and X-ray data of children with CP and crouch gait were retrospectively analyzed if they had received a SEMLS in combination with PTA (PTA group, n = 18) or without PTA (NoPTA group, n = 18). A computational musculoskeletal model was used to quantify patella position, knee extension moment arm, and knee kinematics pre- and postoperatively.

RESULTS

Patellar height significantly decreased in the PTA group (P = 0.004), while there was no difference in the NoPTA group (P > 0.05). The bony procedure for PTA provided a better Insall-Salvati ratio than the soft tissue procedure. The peak knee extension moment arm significantly increased in the PTA group (P = 0.008). In terms of postoperative knee joint kinematics, the PTA group was closer to typically developed children than the NoPTA group.

CONCLUSION

Musculoskeletal modeling was found to be an effective tool for the determination of the patellar height. PTA improved the patella position, knee extension moment arm, and knee kinematics and was an effective procedure for the surgical management of crouch gait in patients with CP.

Instrumented gait analysis for management of gait disorders in children with cerebral palsy: A scoping review

BACKGROUND

The use of Instrumented Gait Analysis (IGA) for the clinical management of individuals with cerebral palsy (CP) has increased in recent years. Previous systematic reviews have been completed to evaluate and summarize the evidence related to the efficacy of IGA in general. However, a focused summary of research studies on IGA for children with CP related gait disorders is needed.

RESEARCH QUESTION

The purpose of the current work was to perform a scoping review to describe and categorize the range of existing literature about IGA as applied to the clinical management of children with CP related gait disorders.

METHOD

A health sciences librarian developed a search strategy to include four key inclusion criteria of original research study, population included children with CP, study employed IGA, available in English. The available literature was organized into six study categories: reliability and validity, documentation of subgroups or model development, IGA for clinical decision making, effectiveness of treatments that depend on IGA, cost effectiveness, IGA used to evaluate the outcome of surgical, medical or rehabilitation treatment.

RESULTS

909 studies met the inclusion criteria and were placed into the six study categories. 14 % of studies were in reliability and validity, 33 % in subgroups or modeling, 2% in IGA for clinical decision making, 2% in treatments that depend on IGA, 1% in cost effectiveness, and 49 % of studies had IGA used as an outcome measure for treatment.

SIGNIFICANCE

This scoping review has documented the wide range, diversity and extent of original research studies investigating the use of IGA for the clinical management of children with CP related gait disorders. The large volume of studies provides a basis for future work to develop a CPG about the use of IGA for the clinical management of children with CP related gait disorders.

The Impact of Patellar Tendon Advancement on Knee Joint Moment and Muscle Forces in Patients with Cerebral Palsy

Background: Patellar tendon advancement (PTA) is performed for the treatment of crouch gait in patients with cerebral palsy (CP). In this study, we aimed to determine the influence of PTA in the context of single-event multilevel surgery (SEMLS) on knee joint moment and muscle forces through musculoskeletal modeling; Methods: Gait data of children with CP and crouch gait were retrospectively analyzed. Patients were included if they had a SEMLS with a PTA (PTA group, n = 18) and a SEMLS without a PTA (NoPTA group, n = 18). A musculoskeletal model was used to calculate the pre- and postoperative knee joint moments and muscle forces; Results: Knee extensor moment increased in the PTA group postoperatively (p = 0.016), but there was no statistically significant change in the NoPTA group (p > 0.05). The quadriceps muscle forces increased for the PTA group (p = 0.034), while there was no difference in the NoPTA group (p > 0.05). The hamstring muscle forces increased in the PTA group (p = 0.039), while there was no difference in the NoPTA group (p > 0.05); Conclusions: PTA was found to be an effective surgery for the treatment of crouch gait. It contributes to improving knee extensor moment, decreasing knee flexor moment, and enhancing the quadriceps and hamstring muscle forces postoperatively.

Review of Tone Management for the Primary Care Provider

Movement disorders in a pediatric population represent a spectrum of secondary functional deficits affecting ease of care, ambulation, and activities of daily living. Cerebral palsy represents the most common form of movement disorder seen in the pediatric population. Several medical and surgical options exist in the treatment of pediatric spasticity and dystonia, which can have profound effects on the functionality of these patients. Given the complex medical and surgical problems in these patients, children are well served by a multidisciplinary team of practitioners, including physical therapists, physical medicine and rehabilitation physicians, and surgeons.

The Ability to Run in Young People with Cerebral Palsy before and after Single Event Multi-Level Surgery

The objective of the study is to identify and evaluate possible factors that influence the ability to run before and after single event multi-level surgery (SEMLS). Young patients (6–25 years) with spastic cerebral palsy (GMFCSI-II) were retrospectively included. Type and number of surgical procedures, time for recovery and 3D gait analysis variables were analyzed with respect to the ability to run. In total, 98 patients (38 females; 60 males) who received SEMLS (12 years, SD 3.4) were included and compared to a control group of 71 conservatively treated patients. Of 60 runners pre-surgery, 17 (28%) lost the ability, while gained in 8 of 38 (21%) non-runners. The number of surgical procedures was a significant predictor and those who lost their ability to run had significantly more (mean = 5.9, SD = 1.7), compared to the patients who gained the ability (mean = 3.5, SD = 0.9). Further, pre-surgical function (e.g., gait speed) was significantly different (p < 0.001). Pre-surgical function and the number of surgical procedures seem to play an important role for the gain or loss of the ability to run after surgery. Caution is warranted in patients with lower pre-surgical function and the ability to run, as they seem at a higher risk to lose the ability.

Single-event multilevel surgery in cerebral palsy: Value added by a co-surgeon

ABSTRACT

The aim of this study was to compare outcomes for single-event multilevel surgery (SEMLS) in cerebral palsy (CP) performed by 1 or 2 attending surgeons.A retrospective review of patients with CP undergoing SEMLS was performed. Patients undergoing SEMLS performed by a single senior surgeon were compared with patients undergoing SEMLS by the same senior surgeon and a consistent second attending surgeon. Due to heterogeneity of the type and quantity of SEMLS procedures included in this study, a scoring system was utilized to stratify patients to low and high surgical burden. The SEMLS events scoring less than 18 points were categorized as low burden surgery and SEMLS scoring 18 or more points were categorized as high burden surgery. Operative time, estimated blood loss, hospital length of stay, and operating room (OR) utilization costs were compared.In low burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 8 patients had SEMLS performed by 2 surgeons. In high burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 12 patients had SEMLS performed by 2 surgeons. For high burden SEMLS, operative time was decreased by a mean of 69 minutes in cases performed by 2 co-surgeons (P = 0.03). Decreased operative time was associated with an estimated savings of $2484 per SEMLS case. In low burden SEMLS, a trend toward decreased operative time was associated for cases performed by 2 co-surgeons (182 vs 221 minutes, P = 0.11). Decreased operative time was associated with an estimated savings of $1404 per low burden SEMLS case. No difference was found for estimated blood loss or hospital length of stay between groups in high and low burden SEMLS.Employing 2 attending surgeons in SEMLS decreased operative time and OR utilization cost, particularly in patients with a high surgical burden. These findings support the practice of utilizing 2 attending surgeons for SEMLS in patients with CP.Level of Evidence: Level III.

Inpatient Exergames for Children with Cerebral Palsy following Lower Extremity Orthopedic Surgery: A Feasibility Study

Objective: Evaluate the feasibility of implementing cycling-based exergames for children with cerebral palsy (CP) following lower extremity orthopedic surgery and explore its impact on pain and well-being.Methods: Ten children with CP were recruited; the first five received physiotherapy (comparison) and next five received fifteen exergame sessions over 3 weeks and physiotherapy (case) (NCT0376907). Feasibility indicators evaluated recruitment, questionnaire and exergame completion. Faces Pain Scale-Revised (FPS-R), PROMIS Pediatric Pain Interference Scale (PPIS), and KIDSCREEN-27 were administered. Wilcoxon signed-rank and effect size (r) tests evaluated within-group differences and between-group differences were assessed using Mann-Whitney U tests.Results: All feasibility indicators were met. Large effects for improved case group pain were identified (FPS-R r = 0.60, PPIS r = 0.58), as well as significant improvement in KIDSCREEN-27 total (U = 0.50, p = .05) and psychological well-being (U = 3.00, p = .01) scores, favoring the case group.Conclusions: Incorporating pediatric exergames is feasible and demonstrates potential for improving pain and well-being.

Factors related to better outcomes after single-event multilevel surgery (SEMLS) in patients with cerebral palsy

BACKGROUND

Good outcomes have been described after single-event multilevel surgery (SEMLS) in cerebral palsy (CP); however, there is limited evidence regarding factors influencing them.

RESEARCH QUESTION

What were the factors related to kinematic outcomes after SEMLS in the present study?

METHODS

Two hundred and fifty-eight patients with spastic diplegic CP, GMFCS I-III, who underwent SEMLS and had done pre and post-operative gait analyses were included in the SEMLS Group (SEMLS-G). A second search was performed in the same database looking for patients to compose the Control Group (CG), and 88 subjects, with at least two gait analyses and with no surgical intervention between tests, were identified. Demographic data, GDI and GPS (Gait Profile Score) were analyzed in both groups, and the results compared. A second evaluation was performed in the SEMLS-G in order to identify the influence of age, gender, follow-up time, pre-operative GDI, GMFCS and gait velocity on results.

RESULTS

The GDI (51.3-58.4) and GPS (2.5°) improvement occurred only in SEMLS-G (p < 0.001). On sagittal plane, there was an improvement at the knee and ankle levels in SEMLS-G, whereas the pelvic alignment improved in the CG. In SEMLS-G, patients with improvement on GDI > 10 points had lower pre-operative GDI (46.15) than other groups (p < 0.001). In addition, patients with reduction on GDI after intervention had lower pre-operative gait velocity than subjects with improvement >10 points (p = 0. 01). The increase on GDI after SEMLS was greater in patients GMFCS I and II than GMFCS III (p = 0.003). There was a negative effect of GMFCS III on GDI improvement after intervention (p = 0.014).

SIGNIFICANCE

Lower pre-operative GDI, higher baseline gait velocity and GMFCS levels I and II were related to better outcomes after SEMLS in the present study. On the other hand, patients GMFCS III were more susceptible to deteriorate after SEMLS.

Evidence Based Position Paper on Physical and Rehabilitation Medicine professional practice for persons with cerebral palsy

INTRODUCTION

Cerebral palsy (CP) is a group of the most common developmental disorders affecting movement and posture of the body, causing activity limitations and participation restrictions. The motor disorders of persons with CP are often accompanied by disturbances of sensation, cognition, communication and perception. The symptoms of CP are very diverse and persons with CP are usually presented with a mixed type of symptoms. The non-progressive disturbances can be attributed to disorders that were developed during pregnancy, birth and/or infant stage.

AIM

The aim of this study was to improve Physical and Rehabilitation Medicine physician´s professional practice for persons with cerebral palsy in order to improve their functionality, social and community integration, and to reduce activity limitations and/or participation restrictions.

MATERIAL AND METHODS

A systematic review of the literature including an eighteen-year period and consensus procedure by means of a Delphi process was performed and involved the delegates of all European countries represented in the Union of European Medical Specialists Physical and Rehabilitation Medicine (UEMS PRM) Section.

RESULTS

As the result of a Consensus Delphi procedure process 74 recommendations are presented together with the systematic literature review.

CONCLUSIONS

The PRM physician´s role for persons with cerebral palsy is to lead and coordinate the multiprofessional team, working in an interdisciplinary way. They should propose and manage the complex but individual PRM programme developed in conjunction with other health professionals, medical specialists and importantly in agreement with the patient, their family and care giver. This should be, according to the specific medical diagnosis to improve patients´ health, functioning, social and education status, considering all impairments, comorbidities and complications, activity limitations and participation restrictions.

Recurrence of knee flexion contracture after surgical correction in children with cerebral palsy

PURPOSE

Knee flexion contracture (FC) and crouch gait are challenging to treat in children with cerebral palsy (CCP), and recurrent knee FC after surgery is a severe complication. The aim was to identify factors associated with recurrent knee FC after surgery.

METHODS

The records of 62 CCP (age 10.6±2.6 years) who underwent surgery and were followed for > six months were reviewed. Knee FC was treated by hamstring lengthening, posterior knee capsulotomy, and femoral shortening/extension osteotomy until full extension was obtained. Kaplan-Meier analysis was used to estimate the probability of the correction being maintained. Cox proportional hazard modeling was used to compare parameters between patients with and without recurrent knee FC, with the time to recurrence as the endpoint. Potential confounding factors were included in the multivariate analysis.

RESULTS

In total, the procedure was performed on 122 knees. The average weight-for-age z score was -1.3±1.2. The average follow-up period was 5.4±4.2 years. Knee FC recurrence was observed in 37 knees (30%). The average recurrence-free time was 4.9 years, with most cases of recurrence (33 knees) occurring within six years after surgery. The factors associated with recurrence were age (HR, 1.19) and a required posterior knee capsulotomy procedure (HR, 4.53).

CONCLUSION

Recurrent knee FC after correction is associated with CCP who are older at the time of operation and when posterior knee capsulotomy is performed. The age at operation should be optimized. The sequence of procedures should be performed only as necessary to minimize the chance of post-operative muscle weakness and recurrence.

Knee and foot contracture occur earliest in children with cerebral palsy: a longitudinal analysis of 2,693 children

Background and purpose - Joint contracture is a common problem among children with cerebral palsy (CP). To prevent severe contracture and its effects on adjacent joints, it is crucial to identify children with a reduced range of motion (ROM) early. We examined whether significant hip, knee, or foot contracture occurs earliest in children with CP.Patients and methods - This was a longitudinal study involving 27,230 measurements obtained for 2,693 children (59% boys, 41% girls) with CP born 1990 to 2018 and registered before 5 years of age in the Swedish surveillance program for CP. The analysis was based on 4,751 legs followed up for an average of 5.0 years. Separate Kaplan-Meier (KM) curves were drawn for each ROM to illustrate the proportions of contracture-free legs at a given time during the follow-up. Using a clustered bootstrap method and considering the child as the unit of clustering, 95% pointwise confidence intervals were generated for equally spaced time points every 2.5 years for each KM curve.Results - Contracture developed in 34% of all legs, and the median time to the first contracture was 10 years from the first examination. Contracture was most common in children with a higher Gross Motor Function Classification System (GMFCS) level. The first contracture was a flexion contracture preventing dorsiflexion in children with GMFCS level I or II and preventing knee extension in children with GMFCS level III to V.Interpretation - Early interventions to prevent knee and foot contractures in children with CP should be considered.

A comparison of conventional and minimally invasive multilevel surgery for children with diplegic cerebral palsy

AIMS

To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP).

METHODS

A retrospective analysis of 19 children following C-MLS, with mean age at surgery of 12 years five months (seven years ten months to 15 years 11 months), and 36 children following MI-MLS, with mean age at surgery of ten years seven months (seven years one month to 14 years ten months), was performed. The Gait Profile Score (GPS) and walking speed were collected preoperatively and six, 12 and 24 months postoperatively. Type and frequency of procedures as part of MLS, surgical adverse events, and subsequent surgery were recorded.

RESULTS

In both groups, GPS improved from the preoperative gait analysis to the six-month assessment with maintenance at 12 and 24 months postoperatively. While reduced at six months in both groups, walking speed returned to preoperative speed by 12 months. The overall pattern of change in GPS and walking speed was similar over time following C-MLS and MI-MLS. There was a median of ten procedures per child as part of both C-MLS (interquartile range (IQR) 8.0 to 11.0) and MI-MLS (IQR 7.8 to 11.0). Surgical adverse events occurred in seven (37%) and 13 (36%) children, with four (21%) and 13 (36%) patients requiring subsequent surgery following C-MLS and MI-MLS, respectively.

CONCLUSION

This study indicates similar improvements in gait kinematics and walking speed 24 months after C-MLS and MI-MLS for children with diplegic CP. Cite this article: Bone Joint J 2021;103-B(1):192-197.

Combined Selective Dorsal Rhizotomy and Single-Event Multilevel Surgery in a Child with Spastic Diplegic Cerebral Palsy: A Case Report

INTRODUCTION

Children with spastic diplegic cerebral palsy (CP) often have functional and gait impairments related to spasticity and loss of range of motion (ROM). Selective dorsal rhizotomy (SDR) and single-event multilevel surgery (SEMLS) are surgical interventions that are used to manage spasticity and functional gait impairments, respectively. This is the first known case report of a child with spastic diplegic CP who underwent combined SDR and SEMLS.

CASE REPORT

Our patient is a 7-year-old girl with spastic diplegic CP, functioning at the Gross Motor Function Classification System (GMFCS) level II, who presented with spasticity and contractures in bilateral lower extremities leading to functional gait impairments, despite conservative management. Combined SDR/SEMLS was offered with the goal of simultaneously managing spasticity and contractures while reducing the need for multiple procedures. Postoperatively, the patient's functional mobility, ROM, spasticity, and strength were assessed at various follow-up intervals. The patient had increased lower extremity weakness and functional decline postoperatively. Persistent genu recurvatum and knee instability required prolonged rehabilitation services, and she demonstrated functional gains with these interventions. At follow-ups, spasticity was resolved and ROM improved. By the 12-month follow-up, the Gross Motor Function Measure-66 was improved to 68.9 (55th percentile) from the preoperative level of 62.1 (35th percentile). By the 30-month follow-up, she was able to participate in novel recreational activities.

DISCUSSION/CONCLUSION

Multidisciplinary teams may consider combined SDR/SEMLS for management of spasticity, gait impairment, and contracture in carefully selected patients with spastic CP.

The orthopaedic aspect of spastic cerebral palsy

Spastic Cerebral Palsy (CP) is the most common form of CP, comprising of 80% of all cases. Spasticity is a type of hypertonia that clinically manifests as dynamic contractures. The dynamic contracture along with the reduced level of physical activity in a child with CP leads to secondary structural and morphological changes in spastic muscle, causing real musculotendinous shortening, known as fixed contractures. When fixed muscle contractures are not treated early, progressive musculoskeletal deformities develop. As a consequence, spastic CP from a static neurological pathology becomes a progressive orthopaedic pathology which needs to be managed surgically. Orthopaedic surgical management of CP has evolved from previous "multi-event single level" procedures to a "single event multilevel" procedures, with changes in selection and execution of treatment modalities. There is increasing evidence that multilevel surgery is an integral and essential part of therapeutic management of spastic CP, but more research is needed to ensure effectiveness of this intervention on all domains of physical disability in CP.

Outcome domains and measures after lower limb orthopaedic surgery for ambulant children with cerebral palsy: an updated scoping review

AIM

To determine the reported outcome domains and measures used to assess lower limb orthopaedic surgery of ambulant children and young people with cerebral palsy (CP) and map these outcomes to the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY) framework.

METHOD

This updated scoping review included studies published between January 2016 and July 2019 in five databases: MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies were included if participants were ambulant individuals with CP aged between 0 and 20 years who had undergone lower limb orthopaedic surgery. Health outcome domains and measures were identified and classified using the ICF-CY framework.

RESULTS

Forty-four eligible studies were identified with a total of 40 different outcome domains recorded. Among eligible studies, 44 (100%) measured body function and structural impairment and seven (16%) measured activity limitation and participation restriction. The most frequently reported outcome was gait pattern (n=37, 84%). Few studies reported adverse effects of surgery (n=13, 30%). Twenty-nine different outcome measures were identified. Patient-reported outcomes measures were used in 10 studies (23%).

INTERPRETATION

The review highlights a heterogeneity in the reported outcome domains and measures used in CP studies. The majority of the reported outcomes focus on the ICF-CY domain of body function and structure. The review also highlights a notable shift towards patient-reported outcomes in recent years. Development of a core outcome set for lower limb orthopaedic surgery would guide researchers to use more consistent and complete measurement sets.