“Just published” – Effect of selective percutaneous myofascial lengthening and functional physiotherapy on walking in children with cerebral palsy: Three-dimensional gait analysis assessment

Abstract

Background

Walking is the most affected motor function in children with cerebral palsy (CP). Orthopaedic surgery is regularly used to improve ambulation in children with CP. Selective Percutaneous Myofascial Lengthening (SPML) is considered the state-of-the art technique for surgical lengthening of spastic/contracted muscles in CP. The purpose of this study was to investigate the effect of combined SPML surgery and postoperative functional physiotherapy on gait function and characteristics of children with spastic cerebral palsy (CP).

Methods

Twenty-six children with spastic CP, aged 5–7 years, Gross Motor Function Classification System (GMFCS) levels II (n = 6), III (n = 12) and IV (n = 8) participated in a quasi-experimental one-group pretest-posttest study with a 9-month follow-up. The Global Motion Graph Deviation Index (MGDI) (including MGDI sub-indices of each joint in each plane of motion) and spatiotemporal parameters of a three-dimensional kinematic gait analysis were used to assess the gait function and characteristics, respectively.

Results

Nine months following SPML and functional physiotherapy, statistically significant improvements (p < 0.05) were noted in the Global MGDI, the MGDIs of sagittal plane knee and ankle motion analysis graphs, and the four most common spatiotemporal measures of gait: walking velocity, stride length, step length, and cadence.

Conclusion

Children with spastic CP seem to gain better overall gait function following SPML procedure and functional physiotherapy, by achieving higher walking velocity, longer stride length and step length, and faster cadence. Further studies with control group and longer follow-up three-dimensional gait analyses are warranted to validate these positive results.

 

Introduction

Cerebral palsy (CP) is the world’s most serious cause of motor disorder in children, which is characterised by atypical neurological and musculoskeletal development [1]. Spastic CP is the most common type of CP, accounting for approximately 80% of all cases [1]. Walking is the most impaired motor function in CP. Ambulant children with bilateral spastic CP demonstrate slower walking velocity, decreased cadence and shorter step length compared to typically developing children [2].

Orthopaedic surgery is one of the most common and popular treatment modalities for improving walking in children with CP [3]. Orthopaedic surgery in terms of single-event multilevel surgery (SEMLS: two or more simultaneous soft-tissue and/or osseous surgical procedures at different levels of the lower limb) [4] is a drastic intervention to simultaneously address the biomechanics of gait [5]. The three-dimensional instrumented gait analysis (3DIGA) has been documented to be a critical measure for an effective surgical decision making and for evaluating the outcomes of an orthopaedic surgery in children with CP [6,7]. However, in order to ensure the optimal functional gain from an orthopaedic surgery, it is necessary to apply an appropriate and effective postoperative physiotherapy programme [3].

Selective Percutaneous Myofascial Lengthening (SPML) represents the newest trend in pediatric orthopaedic surgery [8] for percutaneous lengthening of a spastic shortened muscle [9]. Statistically significant and clinically relevant improvement in gait-related gross motor function were found following SPML procedure and functional physiotherapy in 5-7-year-old children with spastic CP, increasing the amount and level of mobility independence [9]. There are also two-dimensional video-graphic data showed significantly improved ambulatory knee and ankle angle motion following SPML in 3–18-year-old children and adolescents with spastic CP [10,11]. These results are enhanced by the findings of a pilot study suggesting that SPML procedure and functional physiotherapy has the potential to promote overall gait function in 5-7-year-old children with CP, although without demonstrating significant changes in eight of the nine examined spatiotemporal parameters [12]. An expanded study with a larger sample size was consequently needed to better investigate the significance of these preliminary findings and generalise to a larger population [13].

Therefore, the present study was undertaken with a larger sample size of children with spastic CP, in GMFCS levels II to IV, aged 5–7 years, to determine the effects of a combined programme of functional physiotherapy and SPML procedure on gait function and characteristics.

 

Section snippets

Study design

This was a one-group pretest-posttest study (Fig. 1) of children who participated as experimental group in a non-randomised controlled trial (non-RCT) protocol of SPML procedure and functional physiotherapy [9]. Baseline 3DIGA was performed within 4 weeks prior to orthopaedic surgery and post-operative 3DIGA 9 months after orthopaedic surgery and rehabilitation programme. Nine months was considered a sufficient period of time to observe the changes in gait. 3DIGA data were collected at a gait

Study participants

All the children (16 males, 10 females), mean age 6,15 ± 0,73 years with moderate to severe (GMFCS level II, n = 6; level III, n = 12; level IV, n = 8) spastic CP (tetraplegia, n = 11; diplegia, n = 13; hemiplegia, n = 2), who participated in the non-RCT [9] were completed the 3DIGA measurements.

Spatiotemporal parameters

Paired sample t-test showed statistically significant (p < 0.05) changes in six of the nine spatiotemporal parameters following the intervention, with the significance value differing in some parameters 

Discussion

All children in this study underwent 3D kinematic gait analysis before and after minimal invasive SPML surgery and 9-month functional physiotherapy. This investigation examined the changes in spatiotemporal parameters, which are considered more sensitive measures than the angular kinematics of the joints for the assessment of the degree of motor dysfunction in CP [15]. The overall Global MGDI was also calculated, combined with the changes in the R/L MGDIs for each joint [14]. As demonstrated by 

Institutional ethical committee approval

The Scientific and Ethical Council of the ‘Attikon’ University General Hospital, Chaidari, Attica, Greece (EBΔ 2199/14-03-2017) approved the study.

Clinical trial registry

The study has been registered at the Australian New Zealand Clinical Trials Registry (ACTRN12618001535268).

Declaration of competing interest

None.

Acknowledgements

The authors sincerely thanks all the children and their families who participated in the study. A special thanks to Mr Georgios Gkrimas and his team from Gait and Motion Analysis Lab of ELEPAP of Athens, Greece for their willing and kind cooperation in receiving and collecting the kinematic gait analysis data.

 
 

The effectiveness of functional approach in gross motor function of children with cerebral palsy

International Organisation of Physical Therapists in Paediatrics (IOPTP) outstanding poster presentation award

Background: Cerebral palsy is the leading cause of childhood disability, with a number of therapeutic interventions available for optimizing gross motor performance. Emerging novel conceptual frameworks have led to the development of the functional approach, which focuses in learning self-initiated activities, through environmental and task adaptations. Nevertheless, a systematic review and meta-analysis, focused on the efficacy of functional approach on gross motor function, has never been performed before.

Purpose: The aim of this study was to perform a systematic review regarding the effectiveness of functional approach in the improvement of gross motor function in children with cerebral palsy, as well as a meta-analysis comparing functional approach and traditional, child-focused approach.

Methods: Pubmed, EBSCOhost (MEDLINE, CINAHL plus, Academic Search Complete etc) and Physiotherapy Evidence Database (PEDro) were searched from 1990 to March 2016. Selection criteria were studies, with experimental or quasi-experimental or cohort design, which included functional therapy for cerebral palsied children between 2-18 years old and reported gross motor function as an outcome measure. The methodological quality of selected randomized controlled trials was evaluated by PEDro scale. Meta-analysis of the randomized controlled trials was based on both fixed and random effects models. The effect size was expressed via Hedges’ g. The sample heterogeneity was assessed by Cochran’s Q test and I2 index. P=0.05 was taken as level of significance.

Results: Ten studies met the inclusion criteria, four of which were RCTs. Two RCTs were of moderate and two RCTs were of high methodological quality. The RCTs contributed to the analysis for a total of 242 cerebral palsied children: 116 in the functional approach group and 126 children in the child-focused approach group. The meta-analysis of RCTs showed no statistically significant difference in the effectiveness of functional approach compared to child-focused approach ([Total fixed effects: p=0.931, g=-0.011] [Total Random effects: p=0.931, g=-0.011]). There was no also heterogeneity among the studies (Q=0.2 [Df=3, p=0.977] and I2 = 0% (95% CI: 0%-0%).

Conclusion: The functional approach is suggested as an effective physiotherapeutic intervention of improving the gross motor function in children with cerebral palsy and it is shown to be equally efficacious with traditional, child-focused intervention.

Implication: Clinical physiotherapists can effectively apply the functional approach in children with cerebral palsy. However, the equal effectiveness of functional and child-focused approaches allows physiotherapists to choose any of the two interventions that best suits their rehabilitation philosophy and/or the individual circumstances of the child and family.

Health-related quality of life following SPML

Health-related quality of life following selective percutaneous myofascial lengthening and functional physiotherapy in children with cerebral palsy (PO-L-11-SAT1).

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Effects of SPML and Functional Physiotherapy on mobility in children with cerebral palsy

Effects of selective percutaneous myofascial lengthening and functional physiotherapy on mobility in children with cerebral palsy: a non-randomized controlled trial (PO-L-10-SAT2).

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Changes in the mobility of children with cerebral palsy after the SPML method and functional physical therapy

Changes in mobility in children with cerebral palsy after selective percutaneous myofascial lengthening (SPML) and functional physical therapy: preliminary findings. 

Effects of minimally invasive surgery and functional physiotherapy on motor function of children with cerebral palsy: A non-randomised controlled trial

PURPOSE: This non-randomised controlled trial investigated whether a combined programme of functional physiotherapy and minimally invasive orthopaedic surgery improves the level and degree of capacity and performance of gross motor function in children with spastic cerebral palsy (CP)

METHODS: Fifty-two children with spastic CP aged 5–7 years, Gross Motor Function Classification System (GMFCS) levels II-IV, were allocated to two equal groups: experimental group (selective percutaneous myofascial lengthening [SPML] procedure and 9-month functional strengthening physiotherapy programme) and control (standard physiotherapy) groups. At baseline and at the end of the 9-month intervention, the capacity and performance of gross motor function were assessed with the Gross Motor Function Measure (GMFM) D and E subcategories and Functional Mobility Scale (FMS), respectively. The level of gross motor function was measured with the GMFCS RESULTS: There was a statistically significant difference in the post-intervention improvements in the GMFM D (experimental mean difference = 19.63 ± 10.46; control mean difference = 2.40 ± 4.62) and E (experimental mean difference = 19.33 ± 11.82; control mean difference = 4.20 ± 6.26) between experimental and control group (p < 0.001). There was a significant improvement in the GMFCS level and each FMS distance for the experimental group (p < 0.001), but not for the control group (p > 0.05). CONCLUSIONS: SPML procedure combined with functional physiotherapy improves gross motor function in children with spastic CP, by raising the degree and level of motor independence. Download PDF  

Improving gait and lower-limb muscle strength in children with cerebral palsy following SPML & Functional Physiotherapy

BACKGROUND: Selective Percutaneous Myofascial Lengthening (SPML) is an innovative minimally invasive surgical procedure, using micro incisions often combined with alcohol nerve block, for managing muscle contractures and stiffness in children with cerebral palsy (CP). There is lack of evidence of effects of a combined intervention of SPML and physiotherapy on gait function and muscle strength in CP.

OBJECTIVE: This study investigated the change in gait function and muscle strength in children with CP who underwent gait laboratory assessment before and after SPML, combined with obturator nerve blocks, and 9-month post-surgical functional physiotherapy.

METHODS: Ten children with bilateral spastic CP, Gross Motor Function Classification System (GMFCS) level II-IV, age

5-7 years, participated in this study. The Global Gait Graph Deviation Index (Global GGDI) and isometric muscle strength (hand-held dynamometry) were the primary outcome measures. Changes in spatiotemporal gait parameters, gross motor function and GMFCS level were secondarily examined.

RESULTS: A significant improvement of Global GGDI was found (p < 0.05). The mean strength in hip flexors, extensors and adductors, knee extensors, and ankle dorsiflexors increased significantly (p < 0.05). Children improved significantly their GMFCS level and gross motor capacity (p < 0.05).

CONCLUSIONS: SPML procedure combined with functional physiotherapy can improve gait function and lower-limb muscle strength.

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