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Functional Gains after Hamstring Lengthening in patients with Cerebral Palsy

Erika Fichter Erlandson , MD PGY-3 UK Physical Medicine and Rehabilitation. Functional Gains after Hamstring Lengthening in patients with Cerebral Palsy. Cerebral Palsy.

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Functional Gains after Hamstring Lengthening in patients with Cerebral Palsy

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  1. Erika FichterErlandson, MD PGY-3 UK Physical Medicine and Rehabilitation Functional Gains after Hamstring Lengthening in patients with Cerebral Palsy

  2. 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

  3. Classification • Classified by type of movement disorder and\or limbs affected

  4. Cerebral Palsy and Gait Note: Only common muscle spasticity causes listed above. Boney abnormalities and muscle contractures may also affect gait and need to be corrected.

  5. 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

  6. 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

  7. Gross Motor Function Classification System [5]

  8. Gross Motor Function Measure

  9. GMFM

  10. 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?

  11. 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

  12. 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)

  13. Sorted by diagnosis

  14. CP Diplegia Only- Descriptives

  15. Results- GMFCS Level

  16. Results – GMFCS 1

  17. Results – GMFCS 1

  18. Results – GMFCS 2

  19. Results – GMFCS 2

  20. Results – GMFCS 3

  21. Results – GMFCS 3 ** * **indicates stat sig at p=0.01 level; *indicated stat sig at p=0.05 level

  22. Comparison of GMFM D Bare

  23. 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

  24. 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)

  25. Study Limitations • Retrospective Study • Large variation in time to follow-up • No follow-up > 1 year • Some subgroups continue to show small N

  26. 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

  27. References • Bax, M., Goldstein, M., Rosenbaum, P. et al. Proposed definition and classification of cerebral palsy. Dev Med Child Neurology. 2005; 47 (8): 571-6. • Blue Peds Ortho Book • 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): 658-67 • 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: 451-60 • 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. • 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. • 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 • 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. • 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 • 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 • 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 • 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) • 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

  28. Thank You!

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