Functional Gains after Hamstring Lengthening in patients with Cerebral Palsy

Erika Fichter Erlandson, MDPGY-3UK Physical Medicine and Rehabilitation

Cerebral Palsy

Cerebral Palsy: “a group of disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the immature brain.” [1]

3 criteria: Static Brain lesion Neuro-motor control deficit that affects

movement or posture Immature brain

Classification

Classified by type of movement disorder and\or limbs affected

Cerebral Palsy and Gait

Location Impairment Effect

Hip Adductor tone Scissoring gait

Iliopsoas tone Crouch gait/Ant pelvic tilt

Abductor weakness Trendelenburg gait

Rectus tone Limit knee flexion in swing

Knee Hamstring tone Crouch gait

Quad/Ham tone Stiff-knee gait

Ankle Gastroc tone Toe walking/Foot Drop

Posterior Tib tone Foot supination

Note: Only common muscle spasticity causes listed above. Boney abnormalities and muscle contractures may also affect gait and need to be corrected.

Treatment options

Physical/Occupational Therapy Orthoses/Casting Oral Medications Botulinum toxin type A injections Intrathecal Baclofen Pump Operative interventions:

Selective dorsal rhizotomy Muscle lengthening procedures Derotational Osteotomies, etc ,etc

The Thought Process & Purpose

Hamstring lengthening procedures improve gait mechanics , 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

GMFM

Research Question

After undergoing hamstring lengthening do functional measures including Gross Motor Functional Classification Score, Gross Motor Functional Measure, and Functional Mobility Scale significantly change in ambulatory children with cerebral palsy?

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

Research Design

Retrospective study Chart review of patients who hamstring

lengthening between 1993 and 2010 (N= 174)

Included those with pre & post-operative gait analysis

Outcome measures include: Gross Motor Function Classification Scale Gross Motor Function Measure:

▪ Part D (standing) ▪ Part E (walking, running, jumping)

Sorted by diagnosis

Diagnosis Number

Traumatic Brain Injury 1

CP hemiplegia 8

CP Triplegia 3

CP Diplegia** 149**

Hereditary Spastic Paraparesis 5

Spinal Cord Injury 3

Fredrichs Ataxia 1

CP Quadraplegia 4

Total 174

CP Diplegia Only- Descriptives

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

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, O2, ROM, Physical Exam)

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

Analysis of Physical Exam parameters in large cohort including ROM, Strength, etc.

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

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!