Gait analysis and Single-event Multi-level surgery

The Melbourne Experience

Richard BakerProfessor of Clinical Gait Analysis

Clinical scientist• Member of IPEM• Registered with HPC

Me!

• MA Physics and Theoretical Physics

• PhD Biomechanical Engineering

• 7 years Gait Analysis Service Manager Musgrave Park Hospital, Belfast

• 9 years Gait Analysis Service Manager Royal Children’s Hospital, Melbourne

Melbourne, Victoria

Population

Victoria 5.5 millionMelbourne 4.1 million

(Greater Manchester 2.6 million)

120 new cases of CP annually

Royal Children’s Hospital

Optimising gross motor function for children with CPDoing the simple things well

Optimising gross motor function for children with CP• GMFCS (Gross motor classification system)

• Age• Unit/bilateral involvement• Motor type• (CP like conditions)

Level I

Level V

Level III

Level II

Level IV

GMFCS

Palisano et al. DMCN 1997

Revised and extended Palisano et al. DMCN

2008

Robin et al. JBJR-Br 2008

GMFCS and age

Impairments and age

Spasticity

Muscle ContractureJoint contractureBony deformity Weakness

BotoxITBSDR

Exercise?Strenghtening?

Diet?SEMLS

Physiotherapy and orthoses

SEMLS

• Minimum of one procedure at two levels (hip/knee/ankle) on both sides

Typical SEMLS

• Psoas recession• Femoral derotation osteotomy• Semitendinosus transfer• Gastrocnemius recession• Calcaneal lengthening

SEMLS – who for

• GMFCS I rare (too good)• GMFCS II• GMFCS III• GMFCS IV rare (too bad)• GMFCS V never

SEMLS – Why?

ICF WHO 2001

SEMLS – Why?

• Improve gross motor function (not just walking)

• Prevent deterioration

• Increase activity and participation?• Improve quality of life?

SEMLS – When?

• After – maturation of gross motor performance– consolidation of skeleton (particularly feet)

• Before– increased education demands– grumpy adolescence

Pre-operative Processes

• Spasticity management in early childhood

• Surgeon decides surgery is required (8-10 years old)

• Pre-op gait analysis to determine nature of surgery

Pre-admission clinic

• Admitted as “day case”• Child and family get to meet ward

staff• Equipment arranged(orthoses,

walking aids, other OT)• Rehabilitation discussed• Consultation with community physio

In-patient

In-patient • 7 days• No rehab• Appropriate lying

0-3 months

Restricted mobility and therapy• Non weight-bearing 3 weeks• Cast change at 3 weeks• Orthoses delivered 6 weeks.• 6-12 weeks back on feet with Solid

AFOs walking with frame or crutches• 12 weeks: 1st post-op video session

3-6 months

Intensive therapy• Community based (home/school)• Move off frame/crutches• Extending walking distances• Maintain knee extension• 6 months: 2nd post-op video

6-12 months

Routine therapy• Community based (home/school)• Maintain progress• Move off crutches/sticks• Move to hinged orthoses?• 9 months: 3rd post-op video session• 12 months: post-op gait analysis

(outcome assessment)

12-24 months

• Optimum function will not generally be achieved until into the second year.

Video sessions

• Standardised video recording and simplified clinical exam.

• Review by specialist physiotherapist in person and surgeons by video.

• Review progress (walking aids and orthoses)

• Ensure knee extension.

PIP fund

INTERVENTION HOURS PROVIDED

Botox – calves only 6 hours

Botox – multilevel 12 hours

Single level surgery – hemiplegia 6 hours

Single level surgery – diplegia 12 hours

Two level surgery – hemiplegia 12 hours

Two level surgery – diplegia 18 hours

Non-ambulant – hip surgery 12 hours

SEMLS – hemiplegia (bony and soft) 30 hours

SEMLS – diplegia (bony and soft) 70 hours

Gait analysis

• To identify impairments• Basis for planning surgery• Outcome assessment

Impairment focussed assessment

• Aims to identify impairments• Clearly link this to evidence from:

– Instrumented gait analysis– Physical examination

Report

Report

Report

Movement Analysis Profile

Movement Analysis Profile

RCT OF SEMLS

Thomason et al. JBJR-Am 2011

Participants

• 6-12 years old, GMFCS II or III• 11 in SEMLS group• 8 in control group

Results

pre 12 240.0

5.0

10.0

15.0

20.0

GPS scores for surgery and control groups (median and IQR)

surgery

control

GP

S (

degre

es)

pre 12 2450.0

60.0

70.0

80.0

90.0

GMFM scores for surgery and control groups (mean and 95% CI)

surgery

control

GM

FM

pre 12 240.0

20.0

40.0

60.0

80.0

100.0

CHQ Physical function scores for surgery and control groups (mean and 95% CI)

surgerycontrol

GM

FM

AUDIT OF SEMLS

Rutz et al. ESMAC 2011

Participants

• All patients having SEMLS 1995-2008• 121 patients GMFCS II and III

• 48 girls, 73 boys• Age 10.7+/- 2.7

GMFCS

• 113 (93%) no change in GMFCS• 6 children from GMFCS III to II• 2 children from GMFCS II to I• No child deteriorated by GMFCS level

• Children who improved were either marginal or had evidence of earlier deterioration

MAP/GPS

Pelvic tilt

Hip flexion

Knee flexion

Ankle d'flex

Pelvic obliquity

Hip adduct'n

Pelvic rotation

Hip rotation

Foot prog.

GPS

0

10

20

30

40

MAP components

Pre Post

Predictors of GPS change

• Age at surgery• GMFCS• GPS pre-op• No. of procedures• Adverse events• Private health insurance• Previous surgery

GPS

MAP

Pelvic Tilt

Hip Flexion

Knee Flexion

Ankle d'flex

Pelvic obliquity

Hip Adduct'n

Pelvic rotation

Hip rotation

Foot prog.

GPS-5

0

5

10

15

20

25

30

35

Mod Severe Very Severe

Impro

vem

ent

in g

ait

vari

able

score

(degre

es)

MAP

0.0 10.0 20.0 30.0

-10.0

0.0

10.0

20.0

Short (1 year)Linear (Short (1 year))

Pre-operative GPS

Imp

rovem

en

t in

GP

S

N = 47

MAP

0.0 10.0 20.0 30.0

-10.0

0.0

10.0

20.0

Short (1 year)Linear (Short (1 year))

Pre-operative GPS

Imp

rovem

en

t in

GP

S

N = 28

Summary• SEMLS does not change GMFCS

status (but might restore it)• It can help improve walking (GPS)

and more general gross motor functions (GMFM)

Summary• Evidence of mild deterioration over

12 months in absence of intervention

• Optimal outcomes at 2 years, maintained for ten years

• More involved children appear to have more to gain