1. Erika Fichter Erlandson, MD PGY-3 UK Physical Medicine and Rehabilitation

2.  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

3.  Classified by type of movement disorder and\or limbs affected

4. LocationImpairmentEffect Hip Adductor toneScissoring gait Iliopsoas toneCrouch gait/Ant pelvic tilt Abductor weaknessTrendelenburg gait Rectus toneLimit knee flexion in swing Knee Hamstring toneCrouch gait Quad/Ham toneStiff-knee gait Ankle Gastroc toneToe walking/Foot Drop Posterior Tib toneFoot supination Note: Only common muscle spasticity causes listed above. Boney abnormalities and muscle contractures may also affect gait and need to be corrected.

5.  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

6.  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

10.  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?

11.  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

12.  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)

13. DiagnosisNumber Traumatic Brain Injury1 CP hemiplegia8 CP Triplegia3 CP Diplegia**149** Hereditary Spastic Paraparesis5 Spinal Cord Injury3 Fredrichs Ataxia1 CP Quadraplegia4 Total174

14. 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

15. GMFCS LevelPre- NumberPost- Number 12624 24850 375

16. 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

18. 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

20. 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

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

23.  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

24.  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)

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

26.  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

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