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Gait analysis and Single-event Multi-level surgery The Melbourne Experience

Gait analysis and Single-event Multi-level surgery The Melbourne Experience. Richard Baker Professor of Clinical Gait Analysis. Clinical scientist. Member of IPEM Registered with HPC. Me!. MA Physics and Theoretical Physics PhD Biomechanical Engineering

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Gait analysis and Single-event Multi-level surgery The Melbourne Experience

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  1. Gait analysis and Single-event Multi-level surgeryThe Melbourne Experience Richard Baker Professor of Clinical Gait Analysis

  2. Clinical scientist • Member of IPEM • Registered with HPC

  3. Me! • MA Physics and Theoretical Physics • PhD Biomechanical Engineering • 7 years Gait Analysis Service Manager Musgrave Park Hospital, Belfast • 9 years Gait Analysis Service Manager Royal Children’s Hospital, Melbourne

  4. Melbourne, Victoria

  5. Population Victoria 5.5 million Melbourne 4.1 million (Greater Manchester 2.6 million) 120 new cases of CP annually

  6. Royal Children’s Hospital

  7. Optimising gross motor function for children with CP Doing the simple things well

  8. Optimising gross motor function for children with CP • GMFCS (Gross motor classification system) • Age • Unit/bilateral involvement • Motor type • (CP like conditions)

  9. Level I Level II Level III GMFCS Level IV Level V Palisano et al. DMCN 1997 Revised and extended Palisano et al. DMCN 2008

  10. Robin et al. JBJR-Br 2008

  11. GMFCS and age

  12. Impairments and age Muscle Contracture Joint contracture Bony deformity Spasticity Weakness Botox ITB SDR Exercise? Strenghtening? Diet? SEMLS Physiotherapy and orthoses

  13. SEMLS • Minimum of one procedure at two levels (hip/knee/ankle) on both sides

  14. Typical SEMLS • Psoas recession • Femoral derotationosteotomy • Semitendinosus transfer • Gastrocnemius recession • Calcaneal lengthening

  15. SEMLS – who for • GMFCS I rare (too good) • GMFCS II • GMFCS III • GMFCS IV rare (too bad) • GMFCS V never

  16. SEMLS – Why? ICF WHO 2001

  17. SEMLS – Why? • Improve gross motor function (not just walking) • Prevent deterioration • Increase activity and participation? • Improve quality of life?

  18. SEMLS – When? • After • maturation of gross motor performance • consolidation of skeleton (particularly feet) • Before • increased education demands • grumpy adolescence

  19. Pre-operative Processes • Spasticity management in early childhood • Surgeon decides surgery is required (8-10 years old) • Pre-op gait analysis to determine nature of surgery

  20. Pre-admission clinic • Admitted as “day case” • Child and family get to meet ward staff • Equipment arranged(orthoses, walking aids, other OT) • Rehabilitation discussed • Consultation with community physio

  21. In-patient In-patient • 7 days • No rehab • Appropriate lying

  22. 0-3 months Restricted mobility and therapy • Non weight-bearing 3 weeks • Cast change at 3 weeks • Orthoses delivered 6 weeks. • 6-12 weeks back on feet with Solid AFOs walking with frame or crutches • 12 weeks: 1st post-op video session

  23. 3-6 months Intensive therapy • Community based (home/school) • Move off frame/crutches • Extending walking distances • Maintain knee extension • 6 months: 2nd post-op video

  24. 6-12 months Routine therapy • Community based (home/school) • Maintain progress • Move off crutches/sticks • Move to hinged orthoses? • 9 months: 3rd post-op video session • 12 months: post-op gait analysis (outcome assessment)

  25. 12-24 months • Optimum function will not generally be achieved until into the second year.

  26. Video sessions • Standardised video recording and simplified clinical exam. • Review by specialist physiotherapist in person and surgeons by video. • Review progress (walking aids and orthoses) • Ensure knee extension.

  27. INTERVENTION HOURS PROVIDED Botox – calves only 6 hours Botox – multilevel 12 hours Single level surgery – hemiplegia 6 hours Single level surgery – diplegia 12 hours Two level surgery – hemiplegia 12 hours Two level surgery – diplegia 18 hours Non-ambulant – hip surgery 12 hours SEMLS – hemiplegia (bony and soft) 30 hours SEMLS – diplegia (bony and soft) 70 hours PIP fund

  28. Gait analysis • To identify impairments • Basis for planning surgery • Outcome assessment

  29. Impairment focussed assessment • Aims to identify impairments • Clearly link this to evidence from: • Instrumented gait analysis • Physical examination

  30. Report

  31. Report

  32. Report

  33. Movement Analysis Profile

  34. Movement Analysis Profile

  35. RCT of SEMLs Thomason et al. JBJR-Am 2011

  36. Participants • 6-12 years old, GMFCS II or III • 11 in SEMLS group • 8 in control group

  37. Results

  38. Audit of SEMLs Rutz et al. ESMAC 2011

  39. Participants • All patients having SEMLS 1995-2008 • 121 patients GMFCS II and III • 48 girls, 73 boys • Age 10.7+/- 2.7

  40. GMFCS • 113 (93%) no change in GMFCS • 6 children from GMFCS III to II • 2 children from GMFCS II to I • No child deteriorated by GMFCS level • Children who improved were either marginal or had evidence of earlier deterioration

  41. MAP/GPS

  42. Predictors of GPS change • Age at surgery • GMFCS • GPS pre-op • No. of procedures • Adverse events • Private health insurance • Previous surgery

  43. GPS

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