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
Victoria
Melbourne
5.5 million
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 CP
Doing the simple things well
Optimising gross motor
function for children with CP
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GMFCS (Gross motor classification system)
Age
Unit/bilateral involvement
Motor type
(CP like conditions)
Level I
Level II
GMFCS
Level III
Level IV
Level V
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
Muscle Contracture
Joint contracture
Spasticity Bony deformity
Botox
ITB
SDR
SEMLS
Weakness
Exercise?
Strenghtening?
Diet?
Physiotherapy and orthoses
SEMLS
• Minimum of one procedure at two levels
(hip/knee/ankle) on both sides
Typical SEMLS
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Psoas recession
Femoral derotation osteotomy
Semitendinosus transfer
Gastrocnemius recession
Calcaneal lengthening
SEMLS – who for
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GMFCS I
GMFCS II
GMFCS III
GMFCS IV
GMFCS V
rare (too good)
rare (too bad)
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
GPS scores for surgery and control groups
(median and IQR)
20.0
surgery
control
GPS (degrees)
15.0
10.0
5.0
0.0
pre
12
24
GMFM scores for surgery and control groups
(mean and 95% CI)
90.0
surgery
control
GMFM
80.0
70.0
60.0
50.0
pre
12
24
CHQ Physical function scores for surgery and control groups
(mean and 95% CI)
100.0
surgery
80.0
control
GMFM
60.0
40.0
20.0
0.0
pre
12
24
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
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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
MAP components
40
Pre
30
Post
20
10
0
Predictors of GPS change
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Age at surgery
GMFCS
GPS pre-op
No. of procedures
Adverse events
Private health insurance
Previous surgery
GPS
MAP
35
Mod
Severe
Very Severe
Improvement in gait variable score (degrees)
30
25
20
15
10
5
0
-5
Pelvic
Tilt
Hip
Flexion
Knee
Flexion
Ankle
d'flex
Pelvic
obliquity
Hip
Adduct'n
Pelvic
rotation
Hip
rotation
Foot
prog.
GPS
MAP
20.0
Improvement in GPS
Short (1 year)
Medium (5 years)
10.0
0.0
0.0
10.0
20.0
N = 47
-10.0
Pre-operative GPS
30.0
MAP
20.0
Short (1 year)
Improvement in GPS
Long (9 years)
10.0
0.0
0.0
10.0
20.0
N = 28
-10.0
Pre-operative GPS
30.0
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