Functional Gains after Hamstring Lengthening in Patients with Cerebral Palsy

Erika Fichter Erlandson, MDPGY-4UK Physical Medicine and Rehabilitation

The Thought Process & Purpose

Hamstring 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 Question

In 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)

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

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

Research Design

Retrospective study Same patient population as

previously described Outcome measures include:

Gross Motor Function Classification Scale Gross Motor Function Measure Functional Mobility Scale

Descriptive Statistics

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

Results- FMSFMS 5

Meters

50 Meters

500 meters

Wheelchair/Crawl (1) 12 2 57

Post Crawl 8 0 51

Walker (2) 32 51 18

Post Walker 32 48 15

Crutches (3) 18 18 8

Post Crutches 21 22 12

One Crutch (4) 7 6 4

Post One Crutch 5 8 9

No device, decreased balance (5)

62 56 47

Post No device, decrease balance

59 47 38

No device, good balance (6) 18 16 15

Post No device, good balance 24 24 24

WC/C

rawl

Crutc

hes

Decr.

Bala

nce

0

10

20

30

40

50

60

70FMS 5- PreFMS 5- Post

WC/C

rawl

Crutc

hes

Decr.

Bala

nce

0

10

20

30

40

50

60FMS 50- PreFMS 50- Post

WC/C

rawl

One C

rutc

h0

10

20

30

40

50

60 FMS 500- PreFMS 500- Post

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)

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

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

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!