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Erika Fichter Erlandson, MD PGY-4 UK Physical Medicine and Rehabilitation.

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Presentation on theme: "Erika Fichter Erlandson, MD PGY-4 UK Physical Medicine and Rehabilitation."— Presentation transcript:

1 Erika Fichter Erlandson, MD PGY-4 UK Physical Medicine and Rehabilitation

2  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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8  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)

9  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

10  Retrospective study  Same patient population as previously described  Outcome measures include:  Gross Motor Function Classification Scale  Gross Motor Function Measure  Functional Mobility Scale

11 Descriptive Male99 Female50 Age12.07 years +/- 3.27 Pre-Height138.72 cm +/- 17.5 Post-Height148.16 cm +/- 14.5 Pre-Weight39.53 kg +/- 15.9 Post-Weight47.88 kg +/- 16.97 Time to Post-Op Gait Analysis1.76 years +/- 1.28

12 GMFCS LevelPre- NumberPost- Number 12624 24850 375

13 Pre-Op Mean +/- SD Post-Op Mean +/- SD P- value GMFM D- Bare (n=23) 90.87 +/- 5.3591.39 +/- 5.30 0.628 GMFM E-Bare 89.91 +/- 7.8689.61+/- 6.44 0.840 GMFM D- mod (n=5) 87.00 +/- 7.5586.20+/- 10.04 0.881 GMFM E-mod 89.40 +/- 7.5090.00+/- 5.30 0.818

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15 Pre-Op Mean +/- SD Post-Op Mean +/- SD P- value GMFM D- Bare (n=44) 79.84 +/- 13.20779.39 +/- 12.5290.841 GMFM E-Bare 63.82 +/- 17.36863.80 +/- 18.0020.992 GMFM D- mod (n=10) 83.40 +/- 12.35883.20 +/- 8.8790.966 GMFM E-mod 65.20 +/- 9.80765.60 +/- 10.0130.866

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17 Pre-Op Mean +/- SD Post-Op Mean +/- SD P- value GMFM D- Bare (n=70) 44.51 +/- 23.15051.66 +/- 24.266 0.004 GMFM E-Bare 23.06 +/- 14.98027.17 +/- 17.0230.013 GMFM D- mod (n=69) 81.46 +/- 23.03488.46 +/- 12.9030.008 GMFM E-mod 53.48 +/- 16.83554.32 +/- 17.5820.647

18 **indicates stat sig at p=0.01 level;*indicated stat sig at p=0.05 level ** *

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20 FMS 5 Meters 50 Meters 500 meters Wheelchair/Crawl (1)12257 Post Crawl8051 Walker (2)325118 Post Walker324815 Crutches (3)18 8 Post Crutches212212 One Crutch (4)764 Post One Crutch589 No device, decreased balance (5)625647 Post No device, decrease balance594738 No device, good balance (6)181615 Post No device, good balance24

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22  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

23  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)

24  Retrospective Study  Large variation in time to follow-up  No follow-up > 1 year  Some subgroups continue to show small N

25  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

26 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 Book 3. 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): 658-67 4. 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: 451-60 5. 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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