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Erika Fichter Erlandson , MD PGY-3 UK Physical Medicine and Rehabilitation. Functional Gains after Hamstring Lengthening in patients with Cerebral Palsy. Cerebral Palsy. - PowerPoint PPT Presentation
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Functional Gains after Hamstring Lengthening in patients with Cerebral Palsy
Erika Fichter Erlandson, MDPGY-3UK Physical Medicine and Rehabilitation
Cerebral Palsy
Cerebral Palsy: “a group of disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the immature brain.” [1]
3 criteria: Static Brain lesion Neuro-motor control deficit that affects
movement or posture Immature brain
Classification
Classified by type of movement disorder and\or limbs affected
Cerebral Palsy and Gait
Location Impairment Effect
Hip Adductor tone Scissoring gait
Iliopsoas tone Crouch gait/Ant pelvic tilt
Abductor weakness Trendelenburg gait
Rectus tone Limit knee flexion in swing
Knee Hamstring tone Crouch gait
Quad/Ham tone Stiff-knee gait
Ankle Gastroc tone Toe walking/Foot Drop
Posterior Tib tone Foot supination
Note: Only common muscle spasticity causes listed above. Boney abnormalities and muscle contractures may also affect gait and need to be corrected.
Treatment options
Physical/Occupational Therapy Orthoses/Casting Oral Medications Botulinum toxin type A injections Intrathecal Baclofen Pump Operative interventions:
Selective dorsal rhizotomy Muscle lengthening procedures Derotational Osteotomies, etc ,etc
The Thought Process & Purpose
Hamstring lengthening procedures improve gait mechanics , but does it IMPROVE FUNCTION?
The purpose of this study is to assess the functional effects of hamstring lengthening in ambulatory children with cerebral palsy
Gross Motor Function Classification System [5]
Gross Motor Function Measure
GMFM
Research Question
After undergoing hamstring lengthening do functional measures including Gross Motor Functional Classification Score, Gross Motor Functional Measure, and Functional Mobility Scale significantly change in ambulatory children with cerebral palsy?
Hypothesis
GMFCS level will remain unchanged (as seen in the literature) pre- to post-operatively
GMFM D (standing) and E (walking,
running, and jumping) scores will improve after undergoing hamstring lengthening procedure
Research Design
Retrospective study Chart review of patients who hamstring
lengthening between 1993 and 2010 (N= 174)
Included those with pre & post-operative gait analysis
Outcome measures include: Gross Motor Function Classification Scale Gross Motor Function Measure:
▪ Part D (standing) ▪ Part E (walking, running, jumping)
Sorted by diagnosis
Diagnosis Number
Traumatic Brain Injury 1
CP hemiplegia 8
CP Triplegia 3
CP Diplegia** 149**
Hereditary Spastic Paraparesis 5
Spinal Cord Injury 3
Fredrichs Ataxia 1
CP Quadraplegia 4
Total 174
CP Diplegia Only- Descriptives
Descriptive
Male 99
Female 50
Age 12.07 years +/- 3.27
Pre-Height 138.72 cm +/- 17.5
Post-Height 148.16 cm +/- 14.5
Pre-Weight 39.53 kg +/- 15.9
Post-Weight 47.88 kg +/- 16.97
Time to Post-Op Gait Analysis 1.76 years +/- 1.28
Results- GMFCS Level
GMFCS Level
Pre- Number
Post-Number
1 26 24
2 48 50
3 75 75
GMFCS Level
123
Results – GMFCS 1
Pre-Op Mean +/- SD
Post-Op Mean +/- SD
P- value
GMFM D- Bare (n=23) 90.87 +/- 5.35 91.39 +/- 5.30 0.628
GMFM E-Bare89.91 +/- 7.86 89.61+/- 6.44 0.840
GMFM D- mod (n=5)87.00 +/- 7.55 86.20+/- 10.04 0.881
GMFM E-mod89.40 +/- 7.50 90.00+/- 5.30 0.818
Results – GMFCS 1
GMFM D- Bare
GMFM E - Bare
GMFM D- Mod
GMFM E- Mod
83
84
85
86
87
88
89
90
91
92
Pre-OpPost-Op
Results – GMFCS 2
Pre-Op Mean +/- SD
Post-Op Mean +/- SD
P- value
GMFM D- Bare (n=44)79.84 +/- 13.207 79.39 +/- 12.529 0.841
GMFM E-Bare63.82 +/- 17.368 63.80 +/- 18.002 0.992
GMFM D- mod (n=10)83.40 +/- 12.358 83.20 +/- 8.879 0.966
GMFM E-mod65.20 +/- 9.807 65.60 +/- 10.013 0.866
Results – GMFCS 2
GMFM
D- B
are
GMFM
E-B
are
GMFM
D- m
od
GMFM
E-m
od0
102030405060708090
Pre-OpPost-Op
Results – GMFCS 3
Pre-Op Mean +/- SD
Post-Op Mean +/- SD
P- value
GMFM D- Bare (n=70)44.51 +/- 23.150 51.66 +/- 24.266
0.004
GMFM E-Bare23.06 +/- 14.980 27.17 +/- 17.023 0.013
GMFM D- mod (n=69)81.46 +/- 23.034 88.46 +/- 12.903 0.008
GMFM E-mod53.48 +/- 16.835 54.32 +/- 17.582 0.647
Results – GMFCS 3
GMFM
D- B
are*
*
GMFM
E-B
are*
GMFM
D- m
od**
GMFM
E-m
od0
20
40
60
80
100
Pre-OpPost-Op
**
**indicates stat sig at p=0.01 level; *indicated stat sig at p=0.05 level
**
*
Comparison of GMFM D Bare
Pre-Op Post-Op404550556065707580859095
100
GMFCS 1GMFCS 2GMFCS 3
Discussion
When broken down by GMFCS level, the level 3 patients showed statistically and clinically significant improvements in GMFM D (standing) & GMFM E (walking, running, jumping) both when barefoot and with shoes + modifications (i.e. AFO’s)
This suggests that hamstring lengthening may be more functionally important for CP spastic diplegics who are more significantly involved
Study Strengths
Large Cohort = 147 patients Large subgroups (by GMFCS) Amount of data gathered allowed for
analysis in multiple different ways Multiple standardized measures for
analysis of functional change (GMFM, GMFCS, FMS, O2, ROM, Physical Exam)
Study Limitations
Retrospective Study Large variation in time to follow-up No follow-up > 1 year Some subgroups continue to show
small N
Future Studies
Analysis of Physical Exam parameters in large cohort including ROM, Strength, etc.
Comparison of these patients to a group of controls for a cohort study of function after different types of interventions
References
1. Bax, M., Goldstein, M., Rosenbaum, P. et al. Proposed definition and classification of cerebral palsy. Dev Med Child Neurology. 2005; 47 (8): 571-6.
2. Blue Peds Ortho Book3. Adolfsen, S. MD, Ounpuu, S., Bell, K., and DeLuca, P. MD. Kinematic and Kinetic Outcomes after Identical Multilevel Soft
Tissue Surgery in Children with Cerebral Palsy. Journal of Pediatric Orthopedics. 2007; 27 (6): 658-674. Thomason, P., Baker, R., Dodd, K. et Al. Single-Event Multilevel Surgery in Children with Spastic Diplegia: A Pilot
Randomized Controlled Trial. Journal of Bone and Joint Surgery. 2011; 93: 451-605. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galappi B.(1997) Development and reliability of a system to
classify gross motor function in children with cerebral palsy. Dev Med Child Neurol 39: 214–223.6. Sullivan, E PhD, Barnes, D. MD, Linton, J. MS PT, Calmes, J. MS PT, Damiano, D. PhD PT, Oeffinger, D. PhD, Abel, M. MD,
Bagley, A. PhD, Gorton, G., Nicholson, D. PhD PT, Rogers, S. MPH, and Tylkowski, C. MD. Relationships among functional outcome measures used for assessing children with ambulatory CP. Journal of Developmental Medicine and Child Neurology. 2007; 49: 338-44.
7. Damiano, D. PhD PT, Gilgannon, M. MS PT, and Abel, M. MD. Responsiveness and Uniqueness of the Pediatric Outcomes Data Collection Instrument Compared to the Gross Motor Function Measure for Measuring ORthopaedic and Neurosurgical Outcomes in Cerebral Palsy. Journal of Pediatric Orthopedics. 2005; 25 (5): 641-5
8. Nordmark, E. Hagglund, G. and Jarnlo, GB. Reliability of the gross motor function measure in cerebral palsy. Scandanavian Journal of Rehabilitation Medicine. 1997; 29(1): 25-8.
9. Yngve, D. MD, Scarborough, N. PT, Goode, B. MS, and Haynes, R. MD. Rectus and Hamstring Surgery in Cerebral Palsy: A Gait Analysis Study of Results by Functional Ambulation Level. Journal of Pediatric Orthopedics. 2002; 22: 672-6
10. Karol, LA. Surgical management of the lower extremity in ambulatory children with cerebral palsy. Journal of the American Academy of Orthopedic Surgery. 2004; 12: 196-203
11. Adolfsen, S. MD, Ounpuu, S. MSC, Bell, K. MS, and DeLuca, P. MD. Kinematic and Kinetic Outcomes After Identical Multilevel Soft Tissue Surgery in Children with Cerebral Palsy. Journal of Pediatric Orthopedics. 2007; 27(6): 658-67
12. Cuomo, A. MD, Gamradt, S. MD, Kim, C. MD, Pirpiris, M. MBBS, PhD, Gates, P. MD, McCarthy, J. MD, and Otsuka, N. MD. Health-Related Quality of Life Outcomes Improve After Multilevel Surgery in Ambulatory Children with Cerebral Palsy. Journal of Pediatric Orthopedics. 2007; 27 (6): 653-7)
13. Dreher, T. MD, Vegvari, D. MD, Wolf, S. PhD, Geisbusch, A. MD, Gantz, S. MSc, WEnz, W. MD, and Braatz, F. MD. Development of Knee Function After Hamstring Lengthening as a Part of Multilevel Surgery in Children with Spastic Diplegia: A Long-Term Outcome Study. Journal of Bone and Joint Surgery. 2012; 94: 121-30
Thank You!