erika fichter erlandson, md pgy-4 uk physical medicine and rehabilitation
TRANSCRIPT
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Functional Gains after Hamstring Lengthening in Patients with Cerebral Palsy
Erika Fichter Erlandson, MDPGY-4UK Physical Medicine and Rehabilitation
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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
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Gross Motor Function Classification System [5]
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Gross Motor Function Measure [8] (GMFM)
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GMFM
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Functional Mobility Scale [6]
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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)
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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
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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
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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
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Results- GMFCS Level
GMFCS Level
Pre- Number
Post-Number
1 26 24
2 48 50
3 75 75
GMFCS Level
123
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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
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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
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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
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Results – GMFCS 2
GMFM
D- B
are
GMFM
E-B
are
GMFM
D- m
od
GMFM
E-m
od0
102030405060708090
Pre-OpPost-Op
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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
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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
**
*
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Comparison of GMFM D Bare
Pre-Op Post-Op404550556065707580859095
100
GMFCS 1GMFCS 2GMFCS 3
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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
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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
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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
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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)
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Study Limitations
Retrospective Study Large variation in time to follow-up No follow-up > 1 year Some subgroups continue to show
small N
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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
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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
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Thank You!