Longitudinal changes in mobility following single-event multilevel surgery in ambulatory children with cerebral palsy

Pediatric Spastic Wrist Contractures Can Be Well Managed With Wrist Arthrodesis

BACKGROUND

Severe spastic wrist contractures secondary to cerebral palsy (CP) or alike can have significant implications for patient hand function, hygiene, skin breakdown, and cosmesis. When these contractures become rigid, soft tissue procedures alone are unable to obtain or maintain the desired correction. In these patients' wrist arthrodesis is an option-enabling the hand to be stabilized in a more functional position for hygiene, dressing, and general cosmesis, though are patients satisfied?

METHODS

All children who had undergone a wrist arthrodesis for the management of a severe wrist contracture at Shriners Hospital, Portland between January 2016 and January 2021 were identified (n=23). A chart review was undertaken to obtain data-demographic, operative, clinical, and radiographic. All patients were then contacted to participate in 2 patient-reported outcome questionnaires (74% response agreement), a numerical rating scale (NRS), based on the visual analog scale (VAS) and the disability analog scale (DAS). Results were assessed with the aid of descriptive statistics, means and percentages with the primary focus of determining overall patient satisfaction with the procedure.

RESULTS

Twenty-three patients were included in the review, and 74% took part in the prospective survey. Included were 10 patients with hemiplegia, 4 with triplegia, 7 with quadriplegia, 1 with a diagnosis of Rhett syndrome, and 1 with a history of traumatic brain injury. All patients achieved radiologic union by a mean of 8 weeks, and 87% obtained a neutral postoperative wrist alignment. The NRS showed 88% of patients were highly satisfied with their results; specifically, 82% had an improved appearance, 53% improved function, 71% improved daily cares, and 65% improved hygiene. The postoperative DAS score averaged 4.7 of 12 indicating mild disability. When looking at how a patient's diagnostic subtype affected outcome results, patients with triplegia reported less improvement and greater disability on the NRS and DAS, averaging 9.5 (severe disability on the DAS). The GMFCS classification had less correlation with outcomes.

CONCLUSION

Wrist arthrodesis is a good option for the management of pediatric spastic wrist contractures, with limited complications and an overall high patient/carer satisfaction rate.

LEVEL OF EVIDENCE

Level IV-case series.

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.

The cross-cultural adaptation, construct validity, and intra-rater reliability of the functional mobility scale in Brazilian Portuguese for children and adolescents with spina bifida

PURPOSE

The purpose of this study was to perform a cross-cultural adaptation of the Functional Mobility Scale (FMS) to Brazilian Portuguese and analyse its construct validity and intra-rater reliability in a sample of caregivers of children and adolescents with spina bifida (SB).

MATERIAL AND METHODS

The cross-cultural adaptation followed five stages: two forward translations, synthesis, back-translation, committee review and pre-testing (n = 20). Construct validity was assessed by comparing the FMS with the classifications of Hoffer and Schoenmakers (n = 40). Intra-rater reliability was assessed by comparing the ratings of 14 caregivers, on two occasions. Kendall's tau correlation coefficient was used to test the construct validity of the FMS, while the kappa coefficient was used to test intra-rater reliability.

RESULTS

Caregivers reported no difficulties with completing the FMS in Brazilian Portuguese. Construct validity tests showed positive correlations between the distances of 5 m (house), 50 m (school) and 500 m (community) in the FMS and the classifications of Hoffer (τ = 0.84; τ = 0.90; τ = 0.68; p < 0.01) and Schoenmakers (τ = 0.83; τ = 0.89; τ = 0.76; p < 0.01), respectively. Excellent intra-rater reliability (kappa = 0.9-1.0) was found for all three distances in the FMS.

CONCLUSIONS

The FMS in Brazilian Portuguese showed acceptable intra-rater reliability and construct validity when used to measure the mobility level of patients with SB. We recommend its use in clinical practice and research.Implications for RehabilitationA valid and reliable instrument for assessing the mobility of patients with SB;A cross-cultural and adapted FMS in Brazilian Portuguese;An instrument for therapeutic and functional approaches outside the clinicalsetting;The FMS in the Brazilian Portuguese online version shows mistranslations.

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.

Translation, reliability and validity of the Greek functional mobility scale (FMS) for children with cerebral palsy

PURPOSE

To translate and investigate the reliability and validity of the Greek version of the Functional Mobility Scale (FMS).

METHODS

FMS was translated into Greek. Test-retest reliability (Cohen's weighted kappa coefficient, κ_w) and concurrent validity (Spearman's rank correlation coefficient, r_s) of the Greek version of FMS were assessed in children with Cerebral Palsy (CP). Sixty children (mean age 7.82 ± 3.20 years) were recruited. Physical therapists administered the FMS by interviewing parents about their children's mobility status. The Gross Motor Function Classification System (GMFCS) was additionally used for testing concurrent validity.

RESULTS

The translation of the FMS was deemed easy to understand and administer. The Greek FMS was demonstrated to have almost perfect test-retest reliability (κ_w=0.98-1.00), and very strong correlation with the GMFCS (-0.85 ≤ r_s ≤ -0.89, p < 0.001).

CONCLUSIONS

The Greek version of the FMS was shown to be a reliable and valid classification system for CP and can be used with confidence by Greek physical therapists.Implications for rehabilitationThe FMS provides a very simple and practical outcome measure of functional mobility in children with CP.The use of the reliable and valid Greek FMS will enhance the physical therapy assessment process in the Greek population, by offering the feasibility to detect the motor performance changes in children with CP as they grow or following interventions.The current study renders the Greek FMS available for utilization by physical therapists in order to quantify the independent mobility in children with CP.

Early Mobilization Rehabilitation Program for Children With Cerebral Palsy Undergoing Single-Event Multilevel Surgery

PURPOSE

This study investigates functional and technical outcomes to support an early mobilization approach to rehabilitation after single-event multilevel surgery (SEMLS) for children with cerebral palsy (CP), and disseminates innovative guidelines emphasizing early walking.

METHODS

Twenty-three participants with spastic diplegic CP ages 7 through 17 years, Gross Motor Function Classification System levels I to III, who underwent an early mobilization program after SEMLS were reviewed. Outcomes were examined from motion analysis data and clinical documentation.

RESULTS

All participants were able to return to school walking at discharge. At 1-year postoperatively, participants had returned to their prior walking level or better. Change in Gait Deviation Index and Pediatric Outcomes Data Collection Instrument indicated improvements in functional mobility and gait consistent with or greater than the literature.

CONCLUSION

This intensive early mobilization program restores participation in daily activities, walking, and school within the first month postoperatively.

Control of Walking Speed in Children With Cerebral Palsy

BACKGROUND

Children's ability to control the speed of gait is important for a wide range of activities. It is thought that the ability to increase the speed of gait for children with cerebral palsy (CP) is common. This study considered 3 hypotheses: (1) most ambulatory children with CP can increase gait speed, (2) the characteristics of free (self-selected) and fast walking are related to motor impairment level, and (3) the strategies used to increase gait speed are distinct among these levels.

METHODS

A retrospective review of time-distance parameters (TDPs) for 212 subjects with CP and 34 typically developing subjects walking at free and fast speeds was performed. Only children who could increase their gait speed above the minimal clinically important difference were defined as having a fast walk. Analysis of variance was used to compare TDPs of children with CP, among Gross Motor Function Classification System (GMFCS) levels, and children in typically developing group.

RESULTS

Eight-five percent of the CP group (GMFCS I, II, III; 96%, 99%, and 34%, respectively) could increase gait speed on demand. At free speed, children at GMFCS I and II were significantly faster than children at GMFCS level III. At free speed, children at GMFCS I and II had significantly greater stride length than those at GMFCS levels III. At free speed, children at GMFCS level III had significantly lower cadence than those at GMFCS I and II. There were no significant differences in cadence among GMFCS levels at fast speeds. There were no significant differences among GMFCS levels for percent change in any TDP between free and fast walking.

DISCUSSION

Almost all children with CP at GMFCS levels I and II can control the speed of gait, however, only one-third at GMFCS III level have this ability. This study suggests that children at GMFCS III level can be divided into 2 groups based on their ability to control gait speed; however, the prognostic significance of such categorization remains to be determined.

LEVEL OF EVIDENCE

Diagnostic level II.

Physical therapy treatment in children with cerebral palsy after single-event multilevel surgery: a qualitative systematic review. A first step towards a clinical guideline for physical therapy after single-event multilevel surgery

Background:

The aim of this study was to review available evidence for physical therapy treatment (PTT) after single-event multilevel surgery (SEMLS), and to realize a first step towards an accurate and clinical guideline for developing effective PTT for children with cerebral palsy (CP) after SEMLS.

Methods:

A qualitative systematic review (PubMed, Medline, Embase, CINAHL, and the Cochrane Library) investigating a program of PTT after SEMLS in children aged 4–18 years with CP classified by Gross Motor Function Classification System level I–III.

Results:

Six articles meeting the inclusion criteria were selected. The selected studies provide only incomplete descriptions of interventions, and show no consensus regarding PTT after SEMLS. Neither do they show any consensus on the outcome measures or measuring instruments.

Conclusions:

Based on the results of this literature review in combination with our best practice, we propose a preliminary protocol of PTT after SEMLS.

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

CONTEXT

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

RESULTS

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

LIMITATIONS

Data were largely from cohort studies.

CONCLUSIONS

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

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

BACKGROUND

Selective Percutaneous Myofascial Lengthening (SPML) is an innovative minimally invasive surgical procedure, using micro incisions often combined with alcohol nerve block, for managing muscle contractures and stiffness in children with cerebral palsy (CP). There is lack of evidence of effects of a combined intervention of SPML and physiotherapy on gait function and muscle strength in CP.

OBJECTIVE

This study investigated the change in gait function and muscle strength in children with CP who underwent gait laboratory assessment before and after SPML, combined with obturator nerve blocks, and 9-month post-surgical functional physiotherapy.

METHODS

Ten children with bilateral spastic CP, Gross Motor Function Classification System (GMFCS) level II-IV, age 5-7 years, participated in this study. The Global Gait Graph Deviation Index (Global GGDI) and isometric muscle strength (hand-held dynamometry) were the primary outcome measures. Changes in spatiotemporal gait parameters, gross motor function and GMFCS level were secondarily examined.

RESULTS

A significant improvement of Global GGDI was found (p < 0.05). The mean strength in hip flexors, extensors and adductors, knee extensors, and ankle dorsiflexors increased significantly (p < 0.05). Children improved significantly their GMFCS level and gross motor capacity (p < 0.05).

CONCLUSIONS

SPML procedure combined with functional physiotherapy can improve gait function and lower-limb muscle strength.

A single-center retrospective review of factors influencing surgical success in patients with cerebral palsy undergoing corrective hip surgery

PURPOSE

To identify factors associated with success of corrective bony hip surgery among patients with cerebral palsy (CP).

METHODS

A retrospective review was conducted of medical records of patients diagnosed with CP and hip displacement who underwent surgery from 2004 to 2016 at the authors' institution and who had a one-year minimum follow-up. Patient age, sex, Gross Motor Function Classification System (GMFCS) level, surgical procedure(s), type and extent of CP, presence of preoperative and postoperative hip pain, and hip migration percentages (MPs) were recorded. Surgical success was defined as a postoperative MP ⩽ 30% and no hip pain at final follow-up.

RESULTS

Thirty-eight patients (55 hips) met the inclusion criteria. Mean age at surgery was 10.2 years (range, 2-24 years). Mean MP (standard deviation) improved from 64 ± 29% preoperatively to 22 ± 30% at a mean 1.7-year follow-up (p< 0.001). The absence of preoperative hip pain (p= 0.014), surgery after age 5 (p= 0.041), and a milder preoperative MP (p< 0.001) were significantly associated with surgical success.

CONCLUSION

In patients with CP and hip displacement, early preventative correction of hip displacement after age 5 may improve clinical outcomes, though future studies are needed to provide more definitive clinical direction.

Gait Analysis Parameters and Walking Activity Pre- and Postoperatively in Children With Cerebral Palsy

PURPOSE

This study examined the relationship between the Gait Deviation Index (GDI) and walking activity preoperatively and postoperatively.

METHODS

The GDI and walking activity from 74 youth with cerebral palsy (CP) were included in the analysis. The preoperative GDI was calculated using gait parameters collected during a clinical gait analysis 1 to 16 months prior to surgery. The postoperative GDI was calculated using gait parameters collected during a clinical gait analysis 10 to 26 months following surgery.

RESULTS

A weak correlation was present between the change in the average GDI and the change in strides. A moderate correlation was found between the change in the Surgery GDI and the change in strides.

CONCLUSION

Single-event multilevel surgery improves gait deviations in children with CP. However, the improvement in gait pattern has limited correlation with postoperative change in walking activity. Our results demonstrate a need to pair surgical with additional intervention to affect long-term improvements in walking activity.

Evolution of self-care and functional mobility after single-event multilevel surgery in children and adolescents with spastic diplegic cerebral palsy

AIM

To explore the evolution of self-care and functional mobility after multilevel surgery in children and adolescents with spastic diplegic cerebral palsy and to identify factors affecting these outcomes.

METHOD

Thirty-four participants (22 males, 12 females) were evaluated before surgery, and at 2 months, 6 months, 1 year, 18 months, and 2 years after surgery. Self-care was assessed with the Pediatric Evaluation of Disability Inventory Dutch edition. The Mobility Questionnaire47 (MobQues47) and Functional Mobility Scale (FMS) were used to measure functional mobility.

RESULTS

All outcomes revealed a significant decrease 2 months after single-event multilevel surgery (SEMLS) (p-value between <0.001 and 0.02) followed by a significant increase at 6 months (p<0.001 and p=0.045). Between 6 months and 1 year, a significant increase was also revealed for Mobques47 (p<0.001), FMS (p≤0.008), and the Pediatric Evaluation of Disability Inventory Functional Skills Scale (PEDI-FSS) (p=0.001). Improvement continued until 18 months for the PEDI-FSS. Initial score, initial muscle strength, Gross Motor Function Classification System level, age, and number of surgical interventions significantly influenced time trends for self-care and/or functional mobility.

INTERPRETATION

Most preoperative scores are regained at 6 months after SEMLS. Further improvement is seen until 18 months. Participants with a higher functional level before surgery will temporarily lose more than participants with lower initial functional ability, but they also fast regain their function.

WHAT THIS PAPER ADDS

Self-care and functional mobility decrease significantly in the first months after single-event multilevel surgery (SEMLS). Six months after SEMLS most preoperative scores are regained. Impact of SEMLS is more pronounced for functional mobility than for self-care. Muscle strength and functionality at baseline are important influencing factors on the evolution after SEMLS.

The criterion validity and intra-rater reliability of the Japanese version of the Functional Mobility Scale in children with cerebral palsy

OBJECTIVE

The purpose of this study was to develop a Japanese version of the Functional Mobility Scale (FMS), and examine the criterion validity and intra-rater reliability of the FMS in Japan.

METHODS

The translation of the FMS was performed according to international standards for the translation of measurements. For criterion validity, 111 children with cerebral palsy (mean age; 12year 1mo±3year 7mo; range 5-18) were rated the Japanese version of the FMS and Gross Motor Function Classification System (GMFCS). For intra-rater reliability, the Japanese version of the FMS was rated twice by 24 parents of children with cerebral palsy by interview and/or telephone with a one- to two-week interval between assessments.

RESULTS

The criterion validity was confirmed with a strong correlation between GMFCS level and FMS scores (r²=-0.71 to -0.75). For intra-rater reliability, there was a substantial to excellent level of agreement (kappa=0.72-0.87).

CONCLUSION

The study provides evidence of the criterion validity and intra-rater reliability of the Japanese version of the FMS as a measurement of mobility in children with cerebral palsy.

Pre-operative walking activity in youth with cerebral palsy

BACKGROUND

No data are available regarding level of walking activity for youth with cerebral palsy (CP) before undergoing orthopeadic surgery. The goals of this study were to quantify pre-operative walking activity, and determine whether pre-operative values are different from previously defined levels of walking activity in youth with CP.

PROCEDURES

This study retrospectively evaluated pre-operative walking activity in youth with spastic CP, GMFCS levels I-IV. Walking activity was monitored using the StepWatch™. Outcome variables included mean daily strides, percent of day active, and percent of active time at high activity. Differences between GMFCS levels were examined and comparisons were made to published data.

RESULTS

Pre-operative walking activity data from 126 youth with CP were included. All variables demonstrated higher walking activity in youth at GMFCS levels I/II compared to those at GMFCS levels III/IV. When compared to previously defined walking activity levels, pre-operative walking activity was lower.

CONCLUSIONS

Walking activity among pre-operative youth with CP is significantly lower than published data for ambulatory youth with CP. Results suggest that youth with CP who are surgical candidates have less walking activity than youth with CP without surgical needs. Therefore this study should encourage the effort to collect and analyze individual pre-operative data for comparison and evaluation of post-operative functional recovery.

Predictors of outcome after single-event multilevel surgery in children with cerebral palsy

Aims

Single event multilevel surgery (SEMLS) has been shown to improve gait in children with cerebral palsy (CP). However, there is limited evidence regarding long-term outcomes and factors influencing them.

Methods

In total 39 children (17 females and 22 males; mean age at SEMLS ten years four months, standard deviation 37 months) with bilateral CP (20 Gross Motor Function Classification System (GMFCS) level II and 19 GMFCS level III) treated with SEMLS were included. Children were evaluated using gait analysis and the Gait Deviation Index (GDI) before SEMLS and one, two to three, five and at least ten years after SEMLS. A linear mixed model was used to estimate the effect of age at the surgery, GMFCS and follow-up period on GDI.

Results

There was a mean improvement of 12.1 (-15.3 to 45.1) GDI points one year after SEMLS (p <  0.001) and 10.3 (-23.1 to 44.2) GDI points ten years after SEMLS compared with before SEMLS (p < 0.001). GMFCS level III children aged ten to 12 years had the most improvement. The GMFCS III group had more surgical procedures at the index SEMLS (p < 0.001) and during the follow-up period (p = 0.039). After correcting for other factors, age at surgery was the only factor predictive of long-term results. Our model was able to explain 45% of the variance of the change in GDI at the different time points. Take home message: Children with GMFCS III level aged ten to 12 are the benchmark responders to SEMLS in the long-term. Cite this article: Bone Joint J 2016;98-B:278–81.

Computerized Adaptive Tests Detect Change Following Orthopaedic Surgery in Youth with Cerebral Palsy

BACKGROUND

The Cerebral Palsy Computerized Adaptive Test (CP-CAT) is a parent-reported outcomes instrument for measuring lower and upper-extremity function, activity, and global health across impairment levels and a broad age range of children with cerebral palsy (CP). This study was performed to examine whether the Lower Extremity/Mobility (LE) CP-CAT detects change in mobility following orthopaedic surgery in children with CP.

METHODS

This multicenter, longitudinal study involved administration of the LE CP-CAT, the Pediatric Outcomes Data Collection Instrument (PODCI) Transfer/Mobility and Sports/Physical Functioning domains, and the Timed "Up & Go" test (TUG) before and after elective orthopaedic surgery in a convenience sample of 255 children, four to twenty years of age, who had CP and a Gross Motor Function Classification System (GMFCS) level of I, II, or III. Standardized response means (SRMs) and 95% confidence intervals (CIs) were calculated for all measures at six, twelve, and twenty-four months following surgery.

RESULTS

SRM estimates for the LE CP-CAT were significantly greater than the SRM estimates for the PODCI Transfer/Mobility domain at twelve months, the PODCI Sports/Physical Functioning domain at twelve months, and the TUG at twelve and twenty-four months. When the results for the children at GMFCS levels I, II, and III were grouped together, the improvements in function detected by the LE CP-CAT at twelve and twenty-four months were found to be greater than the changes detected by the PODCI Transfer/Mobility and Sports/Physical Functioning scales. The LE CP-CAT outperformed the PODCI scales for GMFCS levels I and III at both of these follow-up intervals; none of the scales performed well for patients with GMFCS level II.

CONCLUSIONS

The results of this study showed that the LE CP-CAT displayed superior sensitivity to change than the PODCI and TUG scales after musculoskeletal surgery in children with CP.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV: case series.

[Bilateral spastic cerebral palsy with ambulatory ability (diplegia): pathophysiology, state of the art of conservative and surgical treatment and rehabilitation]

BACKGROUND

Infantile cerebral palsy is one of the most common diseases resulting in chronic disability and is mostly concomitant with impairment in the ability to walk.

DISEASE PATTERN

Muscle contractions typically develop during the growth phase with subsequent joint contracture and instability as well as bone deformities to various extents. From a biomechanical viewpoint the gait impairment is due to a lever arm dysfunction.

THERAPEUTIC STRATEGIES

The therapy concept is multimodal and involves conservative as well as operative measures. The objectives are to lower the muscle tonus, to avoid muscle and joint contractures and bone deformities and to correct already fixed malformations in order to achieve the best possible function for the patient. Complicated multilevel operations are often necessary to achieve this aim.

CONCLUSION

Extensive knowledge on the biomechanics of gait and the pathobiomechanics of spastic bilateral cerebral palsy are necessary to carry out surgery. Using instrumental gait analyses the biomechanical relationships can be analyzed better and complicated operations can be planned with greater precision.

How does the functional mobility scale relate to capacity-based measures of walking ability in children and youth with cerebral palsy?

This study examined the relationship between walking performance rated on the Functional Mobility Scale (FMS) and measures of walking capacity in children with cerebral palsy (CP). A total of 143 participants with spastic CP (GMFCS levels I to III) were rated on the FMS and had assessment of self-selected walking speed (WS), fast 1 minute walk test (1MWT) and six minute walk test (6MWT). For each FMS distance, children rated 6 had significantly better 6MWT than children scored 5; children rated FMS 2, 3, or 4 had lower walking capacity measures but were not clearly distinguishable from each other. The 6MWT was an independent predictor of variation in FMS score, accounting for 20% to 27% of the variance across the three FMS distances. While walking capacity impacts on community mobility in children with CP much of the variance remains unexplained, suggesting that other factors play an important role.

The Relationship of Gross Motor Functional Classification Scale Level and Hip Dysplasia on the Pattern and Progression of Scoliosis in Children With Cerebral Palsy

PURPOSE

The primary aim of the study was to determine whether progression and magnitude of scoliosis were related to the Gross Motor Functional Classification Scale (GMFCS) and whether laterality (and associated pelvic obliquity) of the spinal curvature affected severity of recurrent hip subluxation in patients with cerebral palsy who had undergone varus derotational osteotomy (VDRO).

METHODS

A total 115 patients underwent VDRO surgery at a single institution between 1980 and 2001. Adequate radiographs were available for 98 patients. Average age at time of VDRO was 6.5 years and follow-up post-VDRO was 8.2 years. Children were divided into lower severity (GMFCS 1-3; 13 patients), high severity (GMFCS 4; 42 patients), and highest severity (GMFCS 5; 43 patients). A single observer measured all spine radiographs using standardized technique. A separate observer measured hip migration index on all pelvis radiographs.

RESULTS

There was a significant increase in coronal deformity over time in each GMFCS category (p < .0001). The GMFCS 1-3 and GMFCS 4 groups had nearly identical time trends, each increasing at roughly 1° to 2° annually, whereas the GMFCS 5 group increased by 3.5°/year (p = .0153). Increasing Cobb angle was not a significant predictor of severity of recurrent subluxation. Furthermore, there was no significant difference in severity of recurrent hip subluxation when hips were evaluated based on whether they were on the same side as the concavity or convexity of the scoliosis (ie, high or low side of pelvic obliquity).

CONCLUSIONS

The relationship between GMFCS and rate of scoliosis progression differed between groups. Severity of hip subluxation did not increase significantly over time after VDRO, nor was it significantly related to magnitude or laterality of scoliosis in children in this cohort.

SIGNIFICANCE

Treatment decisions regarding hip subluxation and scoliosis in patients with cerebral palsy may be made independent of each other.