Clinician Knowledge, Confidence, and Practice Patterns Defining, Identifying, and Quantifying Dystonia in Children: A Cross-Sectional Survey Study.

A survey was completed by 183 clinicians at a pediatric hospital to investigate knowledge, confidence, and practice patterns defining, identifying, and quantifying dystonia in children. The definition of dystonia was correctly identified by 86% of participants. While 88% reported identifying dystonia, only 42% of physicians and therapists reported quantifying dystonia. A weak, significant correlation, rs =.339, p ≤ .001, was found between years of pediatric experience and confidence identifying dystonia. Clinician reported higher confidence levels identifying and quantifying dystonia if they perform a neurological exam. Clinical training initiatives are needed to improve standardization and build confidence in defining, identifying, and quantifying dystonia.

Multivariate functional principal component analysis and k-means clustering to identify kinematic foot types during gait in children with cerebral palsy.

BACKGROUND: Children with neuromuscular disorders, such as cerebral palsy, frequently develop foot deformities, such as equinopronovalgus and equinosupovarus, leading to walking difficulties and discomfort. Traditional assessment methods, including clinical measures and radiographs, often fail to capture the dynamic nature of these deformities, resulting in suboptimal treatment. 3D gait analysis using multisegment foot models offers a more detailed understanding of these deformities. RESEARCH QUESTION: To determine whether the combination of multisegment foot models, multivariate functional principal component analysis, and k-means cluster analyses could identify distinct, clinically relevant foot types in a large pediatric cohort with cerebral palsy. METHODS: This was a retrospective analysis of 3D gait data from 197 patients with cerebral palsy collected using a multisegment foot model. Multivariate functional principal component analysis was used to reduce these data prior to using k-means clustering to identify foot posture clusters. Further analyses, including ANOVA and Fisher's Exact tests, were used to evaluate demographic, radiographic, and gait characteristics to explain the clinical relevance of each cluster. RESULTS: Analysis of kinematic data from 371 feet revealed six clinically significant clusters, with a low misclassification rate of 2 %. One-factor ANOVAs demonstrated significant differences across clusters for all MPCs, whereas no significant differences were noted in basic anthropometric variables. Significant variations were observed in radiographic and gait function variables, and a strong association between GMFCS levels and cluster categorization was identified. SIGNIFICANCE: The novel approach of integrating multivariate functional principal component analysis and k-means clustering identified a spectrum of foot deformities in children with CP, ranging from equinosupovarus to marked equinopronovalgus. This methodology provides an objective classification based on kinematic data and can facilitate improved diagnosis and treatment of cerebral palsy-related foot deformities.

Focal selective dorsal rhizotomy and concurrent deformity correction: a combined approach.

OBJECTIVE: Selective dorsal rhizotomy (SDR) is a neurosurgical procedure to reduce spasticity in children with cerebral palsy and spastic diplegia. The authors developed a procedure called focal SDR for children with spasticity predominantly in the L5 or S1 motor distribution, which can be combined with orthopedic correction of fixed soft-tissue or bony deformity. The authors describe in detail the technique of minimally invasive focal SDR and propose selection criteria. METHODS: The authors conducted a retrospective study of patients who underwent focal SDR at their institution and underwent baseline and 1-year postoperative 3D gait analysis. Modified Ashworth scale (MAS) and Gait Deviation Index (GDI) scores were the primary outcome measures. RESULTS: Ten patients met the study criteria, all with an underlying diagnosis of cerebral palsy. All underwent focal SDR at the unilateral or bilateral S1 level, and 4 additionally underwent focal SDR at the L5 level unilaterally or bilaterally. All but 1 patient underwent concurrent orthopedic surgery. The improvement in spasticity of the plantar flexors, as measured by the MAS score, was 2.2 (p < 0.001). In the patients who underwent L5 focal SDR, there was an improvement in the hamstring MAS score of 1.4 (p = 0.004). The mean improvement in the GDI score following focal SDR was 11 (range -6 to 29, p < 0.001). CONCLUSIONS: Focally impairing spasticity in the gastrocsoleus complex and/or hamstrings muscle group in the setting of less functionally impactful proximal tone is extremely common in cerebral palsy. The novel technique of focal SDR, combined with orthopedic intervention, improves spasticity scores and overall gait mechanics. Further investigation is warranted to define the ideal candidacy and outcomes.

Comparison of outcomes following surgical intervention and inpatient rehabilitation stays in children with cerebral palsy.

INTRODUCTION: Literature is limited on functional outcomes in children with cerebral palsy (CP) following surgical procedures and a subsequent inpatient rehabilitation unit (IRU) stay. OBJECTIVE: To compare functional outcomes and length of stay (LOS) in children with CP following a surgical procedure and IRU stay based on the surgical procedure performed, pattern of involvement, etiology, and Gross Motor Function Classification System (GMFCS) level. DESIGN: Retrospective cohort study. SETTING: Tertiary care pediatrics. PARTICIPANTS: Pediatric patients with CP who underwent one of three surgical procedures followed by an IRU stay. INTERVENTIONS: Selective dorsal rhizotomy (SDR), single-event multilevel orthopedic surgery (SEMLS), or intrathecal baclofen (ITB) pump implantation and subsequent IRU stay. MAIN OUTCOME MEASURES: IRU LOS, Functional Independence Measure for Children (WeeFIM) total score, sub-scores, and efficiency. RESULTS: Children undergoing SDR had a longer LOS (p ≤ .015). Children with spastic diplegia, GMFCS level II, and prematurity-based CP had higher WeeFIM efficiency scores (p ≤ .046, ≤.021, and .034 respectively). Greater changes in WeeFIM™ scores were associated with spastic diplegia, SDR, GMFCS level II, longer LOS, and higher admission scores (p ≤ .045). CONCLUSIONS: Although statistically and functionally significant improvements in children with CP following surgical interventions and an IRU stay were seen, those with higher WeeFIM change scores tended to have spastic diplegia, to have undergone SDR, GMFCS level II, longer LOS, and higher admission scores.