1. Gait analysis and Single-event Multi-level surgery The Melbourne Experience Richard Baker Professor of Clinical Gait Analysis

2. Clinical scientist Member of IPEM Registered with HPC

3. 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

4. Melbourne, Victoria

5. Population Victoria5.5 million Melbourne4.1 million (Greater Manchester 2.6 million) 120 new cases of CP annually

6. Royal Children’s Hospital

8. Optimising gross motor function for children with CP Doing the simple things well

9. Optimising gross motor function for children with CP GMFCS (Gross motor classification system) Age Unit/bilateral involvement Motor type (CP like conditions)

10. Level I Level V Level III Level II Level IV GMFCS Palisano et al. DMCN 1997 Revised and extended Palisano et al. DMCN 2008

11. Robin et al. JBJR-Br 2008

12. GMFCS and age

13. Impairments and age Spasticity Muscle Contracture Joint contracture Bony deformity Weakness Botox ITB SDR Exercise? Strenghtening? Diet? SEMLS Physiotherapy and orthoses

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

15. Typical SEMLS Psoas recession Femoral derotation osteotomy Semitendinosus transfer Gastrocnemius recession Calcaneal lengthening

16. SEMLS – who for GMFCS I rare (too good) GMFCS II GMFCS III GMFCS IV rare (too bad) GMFCS Vnever

17. SEMLS – Why? ICF WHO 2001

18. SEMLS – Why? Improve gross motor function (not just walking) Prevent deterioration Increase activity and participation? Improve quality of life?

19. SEMLS – When? After –maturation of gross motor performance –consolidation of skeleton (particularly feet) Before –increased education demands –grumpy adolescence

20. 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

21. 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

22. In-patient 7 days No rehab Appropriate lying

23. 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: 1 st post-op video session

24. 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

25. 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)

26. 12-24 months Optimum function will not generally be achieved until into the second year.

27. 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.

28. 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

29. Gait analysis To identify impairments Basis for planning surgery Outcome assessment

30. Impairment focussed assessment Aims to identify impairments Clearly link this to evidence from: –Instrumented gait analysis –Physical examination

31. Report

34. Movement Analysis Profile

37. RCT OF SEMLS Thomason et al. JBJR-Am 2011

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

40. Results

45. AUDIT OF SEMLS Rutz et al. ESMAC 2011

46. Participants All patients having SEMLS 1995-2008 121 patients GMFCS II and III 48 girls, 73 boys Age 10.7+/- 2.7

47. 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

48. MAP/GPS

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

50. GPS

51. MAP

52. N = 47

53. MAP N = 28

54. Summary SEMLS does not change GMFCS status (but might restore it) It can help improve walking (GPS) and more general gross motor functions (GMFM)

55. 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