The short-term effects of selective dorsal rhizotomy on gait compared to matched cerebral palsy control groups

Best Paper Award SIAMOC 2023: Use of Gait Profile Score and Gait Variable Score to quantify patient improvement immediately following neuro-orthopedic surgery in patients with cerebral palsy - A prospective cohort study

BACKGROUND

The Gait Profile Score (GPS) and the Gait Variable Score (GVS) are summary measures used to assess the long-term effects of neuro-orthopedic surgery (NOS) in children with cerebral palsy (cwCP).

RESEARCH QUESTION

What are the immediate changes after NOS as assessed by GPS and GVS, and how does GPS variation (ΔGPS) compare to the clinical opinion of the NOS outcome?

METHODS

Prospective single-arm cohort study. CwCP were assessed before NOS and after the first month of weight-bearing. Popliteal angle, ankle passive dorsiflexion (pDF), and spasticity were collected at the bedside. During walking, pain was assessed using NPRS, and speed was obtained from gait analysis data, as well as GPS and GVS. Longitudinal variations were analyzed using the Wilcoxon test. Children were classified as Improved (I), Stable (S), or Worsened (W) according to ΔGPS and the cut-off threshold recommended in literature. Two clinicians independently classified patients either as I, S, or W based on surgical outcome. Agreement between these two classifications was analyzed using Cohen's k.

RESULTS

Twenty cwCP, 11.4 (3.4) years, were included. At the follow-up: the popliteal angle was reduced by 20° (p=0.015); pDF increased by 10° (p<0.001), and triceps surae spasticity decreased (p=0.008). Pain decreased in four children. GPS decreased from 12.7 (range 8.1-27.7) to 11.8 (7.6-17.6) (ES=0.514, p=0.046), despite a decrease in gait speed (p<0.001). GVS better highlighted the effect of NOS after single-level surgery. Clinically, 18/1/1 children were classified I/S/W. Based on ΔGPS, 9/8/3 children were classified I/S/W. Such disagreement (k=0.119, p=0.227) was mainly due to the different focus of the two assessments.

SIGNIFICANCE

Following NOS, immediate improvements in walking kinematics were observed.

Impact of selective dorsal rhizotomy to cerebral palsy children caregivers' burden

PURPOSE

It is known that cerebral palsy (CP) children's caregivers suffer from burden, depression, and stress, impairing their quality of life (QoL). The more severe the CP, the more burden the caregiver has. Psychosocial support, education, therapies, and financial support are inversely related to the level of stress of the caregiver. Most parents of CP patients submitted to selective dorsal rhizotomy (SDR) report improvement not just on spasticity, but also in the functional role of the children, what can impact on caregiver's QoL. Our objective was to evaluate the burden of CP children's caregivers with and without previous SDR.

METHODS

Spastic CP children caregivers were divided into two groups: those who take care of children without previous SDR (control group) and those that children were previously submitted to SDR (surgical group). The burden index was compared between groups using Burden Interview Questionnaire (BIQ). For statistical analysis, we used SPSS.

RESULTS

The control group had enrolled 31 participants and the surgical group 36. The mean GMFCS level on the control and surgical groups was 3.94 ± 1.26 and 3.74 ± 1.12 (p = 0.61), respectively. The surgical group caregivers presented less burden related to the feeling that they should be doing more to their child (p = 0.003) and if they could do a better job in caring (p = 0.032), compared to controls. The total BIQ index was not significantly different between groups (surgical 32.14 ± 12.34 vs. control 36.77 ± 12.77; p = 0.87). Low economic status had a weak correlation to a higher BIQ index (R2 = 0.24). After age-matching, there was a significative higher BIQ index in the control group (p = 0.008).

CONCLUSION

Caregivers of spastic CP children who were previously submitted to SDR presented less burden related to feeling of the amount of given care than those without previous surgery. The impression that they could do a better job with their kids was higher in the control group. The severity of CP and low economic status were related to more burden in both groups. After pairing groups by age, the control group had a significative higher BIQ index compared to the SDR group.

CLINICAL TRIAL REGISTRATION

Trial registration number: CAAE 73407317.6.0000.0068 (Ethical and Research Committee of University of Sao Paulo, Sao Paulo, Brazil, approved on 08/06/2021). All the subjects were freely given an informed consent to participate in the study that was obtained from all participants. Non-consented ones were excluded from the study.

The Contribution of Lower-Body Kinematics to Pitching and Hitting Performance in Baseball: Utilizing the OpenBiomechanics Project

As markerless motion capture systems become more affordable than ever, it is becoming far easier to collect and analyze kinematic data on baseballers. To ensure this data can be used impactfully, coaches and practitioners should possess a good understanding of specific technique characteristics that are associated with enhanced performance in pitchers and hitters. This study used the open-source data provided by Driveline Baseball's OpenBiomechanics Project to evaluate the contribution of lower-body kinematics to pitch velocity and bat speed. In addition to correlational analyses to examine the association between discrete kinematic variables and performance, statistical nonparametric mapping was used to compare slow and fast velocity groups across the entirety of pitching and hitting motions from peak knee height to ball release/contact. It was found that rotation of the trail leg and extension of the lead knee were both associated with performance in pitchers and hitters. Consequently, coaches and practitioners should ensure that individuals possess an adequate level of strength and flexibility to facilitate optimal movement of the trail hip and lead knee during pitching and hitting movements. If deficiencies exist, then training programs should be designed to address these issues and eventually bring about an improvement in performance.

Short-term reduction of ankle spasticity after surgical lengthening of the triceps surae in chronic post-stroke patients: a retrospective cohort study

Introduction

In post-stroke patients with equinovarus foot deformity (EVFD), soft tissue rearrangements may contribute to muscle overactivity when a muscle is stretched or tension is applied. Therefore, we investigated the effects of surgically restoring the triceps surae (TS) length and lengthening ability on TS spasticity.

Methods

This retrospective study included chronic post-stroke patients who underwent neuro-orthopedic surgery inclusive of TS lengthening. TS spasticity was measured using the Modified Tardieu Scale (MTS) before and 1 month after surgery, both with the knee extended (KE) and flexed (KF). MTS variations were analyzed using the Wilcoxon test. The time from stroke onset was compared between patients with and without post-surgical spasticity using the t-test. Statistical significance was set at 5%.

Results

A total of 120 patients with EVFD, aged 57 (12) years, ranging from 1 to 36 years from stroke, were included in the study. The median MTS_KE score significantly decreased from 3 (range 0-4) to 2 (0-4) (p < 0.001) after surgery. The MTS score decreased by ≥1 point in more than half of the sample. Notably, 19 and 32 patients were completely relieved from spasticity (MTS = 0) in the KE and KF conditions, respectively. Post-surgical spasticity did not depend on the time since stroke onset (p = 0.560).

Discussion

TS lengthening led to a short-term reduction of spasticity in 41% and 63% of chronic post-stroke patients in the gastro-soleus complex and soleus, respectively, with complete relief observed in 21% and 30% of the sample. Surgical lengthening can be considered an effective treatment that not only restores joint range of motion but also may reduce spasticity, even in chronic patients.

Multidimensional Outcomes of Selective Dorsal Rhizotomy for Children With Spastic Cerebral Palsy: Single-Level Laminectomy vs Multiple-Level Laminotomy Techniques

BACKGROUND

Selective dorsal rhizotomy (SDR) reduces lower limb spasticity, improves gait patterns, and restores normal physical and social activity in children with spastic cerebral palsy. Single-level laminectomy (SLL) and multiple-level laminotomy (MLL) are 2 surgical approaches for SDR with limited clinical data comparing their postoperative outcomes.

OBJECTIVE

To compare the differences in multidimensional outcomes after SDR between SLL and MLL for children with spastic cerebral palsy.

METHODS

We retrospectively reviewed children who underwent SDR in our hospital from 1997 to 2016. The multidimensional outcomes in spasticity, joint range of motions, gait kinetics, gross motor activities, functional outcomes, and urological outcomes were assessed 1 year postoperatively. Hip dysplasia and scoliosis rate were compared as long-term outcomes.

RESULTS

Sixty children underwent SDR, including 34 SLL patients and 26 MLL patients. Most improvements in multidimensional outcomes were comparable between SLL and MLL. Patients in the SLL group had larger improvements in ankle dorsiflexion in the midstance phase (SLL 7.59° ± 11.48° vs MLL 0.29° ± 11.30°, P = .027). The rate of scoliosis was similar between the 2 surgical approaches (SLL 12.1% vs MLL 15.4%, P = .722).

CONCLUSION

SDR for children with spastic cerebral palsy could provide physical, functional, and urological improvements. SLL achieved a higher degree of improvement in ankle dorsiflexion in the midstance phase. The rate of scoliosis was not significantly increased by multiple-level laminotomy.

Updated Integrated Framework for Making Clinical Decisions Across the Lifespan and Health Conditions

The updated Integrated Framework for Clinical Decision Making responds to changes in evidence, policy, and practice since the publication of the first version in 2008. The original framework was proposed for persons with neurological health conditions, whereas the revised framework applies to persons with any health condition across the lifespan. In addition, the revised framework (1) updates patient-centered concepts with shared clinical decision-making; (2) frames the episode of care around the patient's goals for participation; (3) explicitly describes the role of movement science; (4) reconciles movement science and International Classification of Function language, illustrating the importance of each perspective to patient care; (5) provides a process for movement analysis of tasks; and (6) integrates the movement system into patient management. Two cases are used to illustrate the application of the framework: (1) a 45-year-old male bus driver with low back pain whose goals for the episode of care are to return to work and recreational basketball; and (2) a 65-year-old female librarian with a fall history whose goals for the episode of care are to return to work and reduce future falls. The framework is proposed as a tool for physical therapist education and to guide clinical practice for all health conditions across the lifespan.

Distal rectus femoris surgery in children with cerebral palsy: results of a Delphi consensus project

PURPOSE

The purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method.

METHODS

The panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached.

RESULTS

Consensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade.

CONCLUSION

This study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP.

LEVEL OF EVIDENCE

V.

Energy consumption does not change after selective dorsal rhizotomy in children with spastic cerebral palsy

AIM

To determine whether energy consumption changes after selective dorsal rhizotomy (SDR) among children with cerebral palsy (CP).

METHOD

We retrospectively evaluated net nondimensional energy consumption during walking among 101 children with bilateral spastic CP who underwent SDR (59 males, 42 females; median age [5th centile, 95th centile] 5y 8mo [4y 2mo, 9y 4mo]) compared to a control group of children with CP who did not undergo SDR. The control group was matched by baseline age, spasticity, and energy consumption (56 males, 45 females; median age [5th centile, 95th centile] 5y 8mo [4y 1mo, 9y 6mo]). Outcomes were compared at baseline and follow-up (SDR: mean [SD] 1y 7mo [6mo], control: 1y 8mo [8mo]).

RESULTS

The SDR group had significantly greater decreases in spasticity compared to matched controls (-42% SDR vs -20% control, p<0.001). While both groups had a modest reduction in energy consumption between visits (-12% SDR, -7% control), there was no difference in change in energy consumption (p=0.11) or walking speed (p=0.56) between groups.

INTERPRETATION

The SDR group did not exhibit greater reductions in energy consumption compared to controls. The SDR group had significantly greater spasticity reduction, suggesting that spasticity had minimal impact on energy consumption during walking in CP. These results support prior findings that spasticity and energy consumption decrease with age in CP. Identifying matched control groups is critical for outcomes research involving children with CP to account for developmental changes.