Selective dorsal rhizotomy; evidence on cost-effectiveness from England

Using the gross motor function measure evolution ratio to compare different dosage of hyperbaric treatment with conventional therapies in children with cerebral palsy - could it end the controversy?

The Gross Motor Function Measure is used in most studies measuring gross motor function in children with cerebral palsy. In many studies, including those evaluating the effect of hyperbaric treatment, the Gross Motor Function Measure variations were potentially misinterpreted because of the lack of control groups. The Gross Motor Function Measure Evolution Ratio (GMFMER) uses historical data from the Gross Motor Function Classification System curves and allows to re-analyze previous published studies which used the Gross Motor Function Measure by considering the natural expected evolution of the Gross Motor Function Measure. As the GMFMER is defined by the ratio between the recorded Gross Motor Function Measure score increase and the expected increase attributed to natural evolution during the duration of the study (natural evolution yields a GMFMER of 1), it becomes easy to assess and compare the efficacy of different treatments.

Objective

The objective of this study is to revisit studies done with different dosage of hyperbaric treatment and to compare the GMFMER measured in these studies with those assessing the effects of various recommended treatments in children with cerebral palsy.

Methods

PubMed Searches were conducted to included studies that used the Gross Motor Function Measure to evaluate the effect of physical therapy, selective dorsal rhizotomy, botulinum toxin injection, hippotherapy, stem cell, or hyperbaric treatment. The GMFMER were computed for each group of the included studies.

Results

Forty-four studies were included, counting 4 studies evaluating the effects of various dosage of hyperbaric treatment in children with cerebral palsy. Since some studies had several arms, the GMFMER has been computed for 69 groups. The average GMFMER for the groups receiving less than 2 h/week of physical therapy was 2.5 ± 1.8 whereas in context of very intensive physical therapy it increased to 10.3 ± 6.1. The GMFMER of stem cell, selective dorsal rhizotomy, hippotherapy, and botulinum toxin treatment was, 6.0 ± 5.9, 6.5 ± 2.0, 13.3 ± 0.6, and 5.0 ± 2.9, respectively. The GMFMER of the groups of children receiving hyperbaric treatment were 28.1 ± 13.0 for hyperbaric oxygen therapy and 29.8 ± 6.8 for hyperbaric air.

Conclusion

The analysis of the included studies with the GMFMER showed that hyperbaric treatment can result in progress of gross motor function more than other recognized treatments in children with cerebral palsy.

Selective Dorsal Rhizotomy: Patient Demographics and Postoperative Physical Therapy

BACKGROUND

Selective dorsal rhizotomy (SDR) is a surgical procedure that permanently alters lower extremity spasticity, common in children with spastic cerebral palsy (CP). Intensive postoperative physical therapy (PT) is recommended following SDR. The first purpose of this study is to describe and compare patient demographics between children who received SDR and the population of children with CP at one institution. The second purpose of this study is to compare the completed dose of postoperative PT with the clinically recommended dose for a subset of ambulatory children who underwent SDR.

METHODS

This retrospective, observational study included 60 children with spastic CP following SDR. A subset (n = 12 ambulatory children) was included to describe the dose of postoperative PT. Information gathered from electronic medical records included age at the time of SDR, sex, Gross Motor Function Classification System level, anatomic distribution, race, county-level habitancy, health insurance provider, timed current procedural terminology codes, and location for postoperative PT encounters within a single institution.

RESULTS

Black or African American children (P = 0.002), children living in large central metro areas (P = 0.033), and children with public insurance (P ≤ 0.001) were significantly less likely to receive SDR. Children undergoing SDR do not achieve the recommended dose of PT after hospital discharge.

CONCLUSION

SDR is not equally accessed by patient populations, and postoperative PT frequency is below current recommendations throughout the rehabilitation process. Future studies need to investigate why these disparities exist and what prevents children from meeting the clinically recommended dose of postoperative PT after SDR.