Improving gait and lower-limb muscle strength in children with cerebral palsy following Selective Percutaneous Myofascial Lengthening and functional physiotherapy

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.

Improving health-related quality of life in middle-age children with cerebral palsy following selective percutaneous myofascial lengthening and functional physiotherapy

INTRODUCTION AND OBJECTIVES

Children with cerebral palsy (CP) experience decreased health-related quality of life (HRQOL). This study aimed to assess the HRQOL of children with CP before versus after a combined program of minimally invasive selective percutaneous myofascial lengthening (SPML) and functional physiotherapy.

MATERIAL AND METHODS

A single-group pre-posttest design was used. Twenty-six middle childhood children with spastic CP, aged 5-7 years, with Gross Motor Function Classification System levels II-IV underwent SPML surgery and 9 months of postoperative functional strength training therapy. The proxy version of the DISABKIDS-Smiley questionnaire was completed by one parent of each child. Dependent t-tests were used to compare mean pre- and post-measurement scores.

RESULTS

After the 9-month intervention, the children with CP had significantly higher quality of life scores (mean difference, 11.06 ± 9.05; 95% confidence interval [CI], 7.40-14.71; p < 0.001).

CONCLUSIONS

This study demonstrated that children with CP had better HRQOL after a combined program of minimally invasive SPML surgery and functional physiotherapy (ACTRN12618001535268).

Influence of the percutaneous myofasciotomy on gait of children with spastic cerebral palsy - A short term, retrospective controlled analysis

BACKGROUND

One of the primary causes in children with cerebral palsy (CP) leading to gait disorders is an increased muscle tone which may secondary result in a shortening of the muscle fascia. Percutaneous myofasciotomy (pMF) is a minimal-invasive surgical intervention correcting the shortened muscle fascia and aims to extend the range of motion.

RESEARCH QUESTION

What is the effect of pMF on gait in children with CP three months and one year post-OP?

METHODS

Thirty-seven children (f: n = 17, m: n = 20; age: 9,1 ± 3,9 years) with spastic CP (GMFCS: I-III, bilateral (BSCP): n = 24, unilateral (USCP): n = 13) were retrospectively included. All children underwent a three dimensional gait analysis with the Plug-in-Gait-Model before (T0) and three months after pMF (T1). Twenty-eight children (bilateral: n = 19, unilateral: n = 9) underwent a one-year follow-up-measurement (T2). Differences in the Gait Profile Score (GPS), kinematic gait data, gait-related functions and mobility in daily living were statistically analyzed. Results were compared to a control group (CG) matched in age (9,5 ± 3,5 years), diagnosis (BSCP: n = 17; USCP: n = 8) and GMFCS-level (GMFCS I-III). This group was not treated with pMF but underwent two gait analyses in twelve months.

RESULTS

The GPS improved significantly in BSCP-pMF (16,46 ± 3,71° to 13,37 ± 3,19°; p < .0001) and USCP-pMF (13,24 ± 3,27° to 10,16 ± 2,06°; p = .003) from T0 to T1 with no significant difference between T1 and T2 in both groups. In CG there was no difference in the GPS between the two analyses.

SIGNIFICANCE

PMF may in some children with spastic CP improve gait function three months as well as for one-year post-OP. Medium and long-term effects, however, remain unknown and further studies are needed.

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.

Clinical Phenotype of Cerebral Palsy Depends on the Cause: Is It Really Cerebral Palsy? A Retrospective Study

Cerebral palsy is the most common motor disability in childhood. Still, the precise definition in terms of causes and timing of the brain damage remains controversial. Several studies examine the clinical phenotype of cerebral palsy types. The aim of our study was to determine to what extent the clinical phenotype of cerebral palsy patients depends on the underlying cause. We retrospectively evaluated the clinical phenotype, abnormalities during pregnancy, and cerebral palsy cause of 384 patients, treated at Charité-Medicine University, between 2015 and 2017. The cause of cerebral palsy was identified in 79.9% of cases. Causes prior to the perinatal period were, compared to perinatal brain damage, associated significantly with different comorbidities. The term cerebral palsy does not describe a single disease but is an umbrella term covering many different diseases. Depending on the cause, a varying clinical phenotype can be found, which offers great potential in terms of individual treatment and preventing comorbidities.

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.

Minimally Invasive SPML Surgery for Children with Cerebral Palsy: Program Development

Improvements in surgical and rehabilitation care are critical to lessen the burden of cerebral palsy (CP), the most common cause of severe physical disability in childhood. The selective percutaneous myofascial lengthening (SPML) surgical procedure is a minimally invasive method designed to improve ambulation by lengthening contracted musculoskeletal tissues. Information on surgical procedures, efficacy, and safety of SPML for children with CP is lacking. Phase 1 of our research is a “proof-of-principle” study for multisite SPML to improve functional mobility of children with CP, and Phase 2 assesses safety, reoperation rates, and efficacy over time in subsequent patient series. Phase 1 was a repeated measurement case series study of 17 children (mean age 7.6 years). One physical therapist, blinded to the surgeon's measurements, measured bilateral knee and ankle motion before and after SPML procedures, using video recordings of a standardized gait path. Functional Mobility Scale (FMS) 5, 50, and 500 outcomes were taken pre- and postoperatively and via telephone follow-up. In Phase 2, multisite SPLM surgeries were implemented in larger successive cohorts from 2006 to 2017. Complications, reoperation rates, and efficacy were retrospectively analyzed. Phase 1 results showed improvement in the children's knee and ankle motion while ambulating and improved FMS 5, 50, and 500 outcomes postoperatively (mean, 6.3 months). At second follow-up (mean 33.3 months), FMS 500 scores continued improvement, while FMS 5 and FMS 50 scores maintained. During Phase 2, the complication rate was 2.4%, and reoperation rates (including reoperations due to maturation) were between 8% and 13%. Improvements to correct ankle equinus were recorded in 498 cases. In conclusion, in a specialized center, single-event, multilevel SPML surgeries of children with CP safely improved ambulatory knee and ankle angle motion and daily mobility outcomes. Future educational studies of training needs for surgeons new to the approach are needed.

The Effect of Cerebral Palsy Disease Severity, Socioeconomic Status, and Educational Background on Selective Percutaneous Myofascial Lengthening Reoperation Rates

Cerebral palsy (CP) is a neuro-developmental disorder. Spastic CP is the most common type of CP and is characterized by contractures of the extremities. Selective Percutaneous Myofascial Lengthening (SPML) is a minimally invasive procedure practiced by a handful of physicians in the US, and it decreases contractures and increases the range of motion in individuals with spastic CP. This study wanted to examine if there was an association between CP severity, socioeconomic status, and reoperation rates. This study used electronic medical records (EMR) to include 626 patients with spastic CP who had surgeries between January 2006 and December 2012. The zip codes from the EMR were used to determine the inflation-adjusted mean income and educational qualification (a high school education or higher) of the community via the US Census Bureau. Disease severity before the initial surgery was determined by using the functional mobility scale in the EMR to compute the Gross Motor Function Classification System (GMFCS) level. Then the data was graphed and averages were taken for the reoperation versus the no-reoperation populations, and Student's t-tests were run to determine statistical significance. The data showed that communities with higher education and income tended to reoperate more often. The higher number of reoperations in affluent communities could mean that either more affluent communities are better educated and know the benefits of bringing their children back for reoperation or that they require further education about physical therapy after the initial surgery to decrease the incidence of reoperation. This retrospective study is a level 2 study looking at the socioeconomic and educational backgrounds and disease severity and their association with reoperation rates.

A Review of the Theoretical Fascial Models: Biotensegrity, Fascintegrity, and Myofascial Chains

The fascial tissue includes solid and liquid fascia (body fluids such as blood and lymph). The fascia's nomenclature is the subject of debate in the academic world, as it is classified starting from different scientific perspectives. This disagreement is not a brake but is, in reality, the real wealth of research, the multidisciplinarity of thought and knowledge that leads to a deeper understanding of the topic. Another topic of discussion is the fascial model to conceptualize the human body, that is, how the fascial tissue fits into the living. Currently, there are some models: biotensegrity, fascintegrity, and myofascial chains. Biotensegrity is a mechanical model, which takes into consideration the solid fascia; fascintegrity considers the solid and the liquid fascia. Myofascial chains converge attention on the movement and transmission of force in the muscle continuum. The article is a reflection on fascial models and how these are theoretical-scientific visions that need to be further investigated.

Association between Gait Deviation Index and Physical Function in Children with Bilateral Spastic Cerebral Palsy: A Cross-Sectional Study

This study examined the association between Gait Deviation Index (GDI) and the five-times-sit-to-stand test (FTSST) or gait speed results, which represent mobility and muscle strength of the lower extremities in ambulatory children with Gross Motor Function Classification System (GMFCS) level I and II spastic cerebral palsy. In this cross-sectional, observational study, three-dimensional gait analysis data were obtained during gait trials to evaluate the GDI in 35 children (age 5–16 years) with spastic palsy. Motor function was evaluated using FTSST and gait speed. Gross motor function was evaluated using GMFCS. Children with GMFCS level II spastic cerebral palsy demonstrated lower GDI (p < 0.001) and poorer FTSST (p = 0.031) than those with GMFCS level I spastic cerebral palsy. Correlation analysis showed that FTSST results were significantly correlated with GDI (r = −0.624; p < 0.001). Motor function may be important for the maintenance of gait quality in patients with GMFCS level I and II spastic cerebral palsy and should not be ignored. In conclusion, reduction in gait impairment may affect the values of FTSST and GDI in patients with spastic cerebral palsy who can ambulate without an assistive device.