Erika Fichter Erlandson, MD PGY-4 UK Physical Medicine and Rehabilitation

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Transcript of Erika Fichter Erlandson, MD PGY-4 UK Physical Medicine and Rehabilitation

Functional Gains after Hamstring Lengthening in patients with Cerebral Palsy

Functional Gains after Hamstring Lengthening in Patients with Cerebral PalsyErika Fichter Erlandson, MDPGY-4UK Physical Medicine and RehabilitationThe Thought Process & PurposeHamstring lengthening procedures improve gait kinematics , 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 [8] (GMFM)

GMFM

Functional Mobility Scale [6]

Research QuestionIn ambulatory children with CP who undergo hamstring lengthening is there significant change in the following functional measures: Gross Motor Functional Classification Score (GMFCS) Gross Motor Functional Measure (GMFM) Functional Mobility Scale (FMS)

HypothesisGMFCS 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

FMS level will remain largely unchanged but will be superior to GMFCS in detecting functional improvement

Research DesignRetrospective studySame patient population as previously describedOutcome measures include: Gross Motor Function Classification Scale Gross Motor Function MeasureFunctional Mobility ScaleDescriptive StatisticsDescriptiveMale99Female50Age12.07 years +/- 3.27Pre-Height138.72 cm +/- 17.5Post-Height148.16 cm +/- 14.5Pre-Weight39.53 kg +/- 15.9Post-Weight47.88 kg +/- 16.97Time to Post-Op Gait Analysis1.76 years +/- 1.28Results- GMFCS LevelGMFCS LevelPre- NumberPost-Number1 26242 485037575

Results GMFCS 1Pre-Op Mean +/- SDPost-Op Mean +/- SDP- valueGMFM D- Bare (n=23) 90.87 +/- 5.3591.39 +/- 5.300.628GMFM E-Bare89.91 +/- 7.8689.61+/- 6.440.840GMFM D- mod (n=5)87.00 +/- 7.5586.20+/- 10.040.881GMFM E-mod89.40 +/- 7.5090.00+/- 5.300.818Results GMFCS 1Results GMFCS 2Pre-Op Mean +/- SDPost-Op Mean +/- SDP- valueGMFM D- Bare (n=44)79.84 +/- 13.20779.39 +/- 12.5290.841GMFM E-Bare63.82 +/- 17.36863.80 +/- 18.0020.992GMFM D- mod (n=10)83.40 +/- 12.35883.20 +/- 8.8790.966GMFM E-mod65.20 +/- 9.80765.60 +/- 10.0130.866Results GMFCS 2Results GMFCS 3Pre-Op Mean +/- SDPost-Op Mean +/- SDP- valueGMFM D- Bare (n=70)44.51 +/- 23.150

51.66 +/- 24.266

0.004GMFM E-Bare23.06 +/- 14.98027.17 +/- 17.0230.013GMFM D- mod (n=69)81.46 +/- 23.03488.46 +/- 12.9030.008GMFM E-mod53.48 +/- 16.83554.32 +/- 17.5820.647Results GMFCS 3**indicates stat sig at p=0.01 level;*indicated stat sig at p=0.05 level***Comparison of GMFM D BareResults- FMSFMS5 Meters50 Meters500 metersWheelchair/Crawl (1)12257Post Crawl8051Walker (2)325118Post Walker324815Crutches (3)18188Post Crutches212212One Crutch (4)764Post One Crutch589No device, decreased balance (5)625647Post No device, decrease balance594738No device, good balance (6)181615Post No device, good balance242424DiscussionWhen 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. AFOs)

This suggests that hamstring lengthening may be more functionally important for CP spastic diplegics who are more significantly involvedStudy StrengthsLarge Cohort = 147 patientsLarge subgroups (by GMFCS)Amount of data gathered allowed for analysis in multiple different waysMultiple standardized measures for analysis of functional change (GMFM, GMFCS, FMS)

Study LimitationsRetrospective StudyLarge variation in time to follow-upNo follow-up > 1 yearSome subgroups continue to show small N

Future Studies

Comparison of these patients to a group of controls for a cohort study of function after different types of interventions

Comparison of subjects with different types of surgeries and interventions

Longitudinal analysis of function over time

ReferencesBax, 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 BookAdolfsen, 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): 658-67Thomason, 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: 214223.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): 641-5Nordmark, 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: 672-6Karol, LA. Surgical management of the lower extremity in ambulatory children with cerebral palsy. Journal of the American Academy of Orthopedic Surgery. 2004; 12: 196-203Adolfsen, 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): 658-67Cuomo, 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

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