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.