Gait analysis and Single-event Multi-level surgery The Melbourne Experience Richard Baker Professor 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 Victoria5.5 million Melbourne4.1 million (Greater Manchester 2.6 million) 120 new cases of CP annually

Royal Children’s Hospital

Optimising gross motor function for children with CP Doing 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 Contracture Joint contracture Bony deformity Weakness Botox ITB SDR 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 Vnever

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 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 weeks back on feet with Solid AFOs walking with frame or crutches 12 weeks: 1 st 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: 2 nd post-op video

6-12 months Routine therapy Community based (home/school) Maintain progress Move off crutches/sticks Move to hinged orthoses? 9 months: 3 rd 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 INTERVENTIONHOURS PROVIDED Botox – calves only6 hours Botox – multilevel12 hours Single level surgery – hemiplegia6 hours Single level surgery – diplegia12 hours Two level surgery – hemiplegia12 hours Two level surgery – diplegia18 hours Non-ambulant – hip surgery12 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

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

AUDIT OF SEMLS Rutz et al. ESMAC 2011

Participants All patients having SEMLS 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

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

GPS

MAP

N = 47

MAP 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