Gait analysis and Single-event Multi-level surgery The Melbourne Experience
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Transcript of Gait analysis and Single-event Multi-level surgery The Melbourne Experience
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Gait analysis and Single-event Multi-level surgeryThe Melbourne ExperienceRichard BakerProfessor of Clinical Gait Analysis
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Clinical scientist• Member of IPEM• Registered with HPC
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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
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Melbourne, Victoria
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Population
Victoria 5.5 millionMelbourne 4.1 million
(Greater Manchester 2.6 million)
120 new cases of CP annually
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Royal Children’s Hospital
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Optimising gross motor function for children with CPDoing the simple things well
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Optimising gross motor function for children with CP• GMFCS (Gross motor classification system)• Age• Unit/bilateral involvement• Motor type• (CP like conditions)
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Level I
Level V
Level III
Level II
Level IV
GMFCS
Palisano et al. DMCN 1997
Revised and extended Palisano et al. DMCN
2008
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Robin et al. JBJR-Br 2008
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GMFCS and age
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Impairments and age
Spasticity
Muscle ContractureJoint contractureBony deformity Weakness
BotoxITBSDR
Exercise?Strenghtening?
Diet?SEMLS
Physiotherapy and orthoses
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SEMLS
• Minimum of one procedure at two levels (hip/knee/ankle) on both sides
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Typical SEMLS
• Psoas recession• Femoral derotation osteotomy• Semitendinosus transfer• Gastrocnemius recession• Calcaneal lengthening
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SEMLS – who for
• GMFCS I rare (too good)• GMFCS II• GMFCS III• GMFCS IV rare (too bad)• GMFCS V never
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SEMLS – Why?
ICF WHO 2001
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SEMLS – Why?
• Improve gross motor function (not just walking)
• Prevent deterioration
• Increase activity and participation?• Improve quality of life?
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SEMLS – When?
• After – maturation of gross motor performance– consolidation of skeleton (particularly feet)
• Before– increased education demands– grumpy adolescence
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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
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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
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In-patient
In-patient • 7 days• No rehab• Appropriate lying
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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
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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
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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)
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12-24 months
• Optimum function will not generally be achieved until into the second year.
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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.
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PIP fundINTERVENTION 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
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Gait analysis
• To identify impairments• Basis for planning surgery• Outcome assessment
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Impairment focussed assessment
• Aims to identify impairments• Clearly link this to evidence from:
– Instrumented gait analysis– Physical examination
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Report
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Report
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Report
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Movement Analysis Profile
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Movement Analysis Profile
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RCT OF SEMLS
Thomason et al. JBJR-Am 2011
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Participants
• 6-12 years old, GMFCS II or III• 11 in SEMLS group• 8 in control group
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Results
pre 12 240.0
5.0
10.0
15.0
20.0
GPS scores for surgery and control groups (median and IQR)
surgerycontrol
GPS
(de
gree
s)
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pre 12 2450.0
60.0
70.0
80.0
90.0
GMFM scores for surgery and control groups (mean and 95% CI)
surgerycontrol
GM
FM
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pre 12 240.0
20.0
40.0
60.0
80.0
100.0
CHQ Physical function scores for surgery and control groups (mean and 95% CI)
surgerycontrol
GM
FM
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AUDIT OF SEMLS
Rutz et al. ESMAC 2011
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Participants
• All patients having SEMLS 1995-2008• 121 patients GMFCS II and III
• 48 girls, 73 boys• Age 10.7+/- 2.7
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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
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MAP/GPS
Pelvic tilt
Hip flexion
Knee flexion
Ankle d'flex
Pelvic obliquity
Hip adduct'n
Pelvic rotation
Hip rotation
Foot prog.
GPS0
10
20
30
40
MAP components
Pre Post
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Predictors of GPS change
• Age at surgery• GMFCS• GPS pre-op• No. of procedures• Adverse events• Private health insurance• Previous surgery
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GPS
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MAP
Pelvic Tilt
Hip Flexion
Knee Flexion
Ankle d'flex
Pelvic obliquity
Hip Adduct'n
Pelvic rotation
Hip rotation
Foot prog.
GPS-5
0
5
10
15
20
25
30
35Mod Severe Very Severe
Impr
ovem
ent
in g
ait
varia
ble
scor
e (d
egre
es)
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MAP
0.0 10.0 20.0 30.0
-10.0
0.0
10.0
20.0
Short (1 year)Linear (Short (1 year))
Pre-operative GPS
Impr
ovem
ent
in G
PS
N = 47
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MAP
0.0 10.0 20.0 30.0
-10.0
0.0
10.0
20.0
Short (1 year)Linear (Short (1 year))
Pre-operative GPS
Impr
ovem
ent
in G
PS
N = 28
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Summary• SEMLS does not change GMFCS
status (but might restore it)• It can help improve walking (GPS)
and more general gross motor functions (GMFM)
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Summary• Evidence of mild deterioration over
12 months in absence of intervention
• Optimal outcomes at 2 years, maintained for ten years
• More involved children appear to have more to gain