Intramuscular psoas lengthening at the pelvic brim plus proximal lengthening of the rectus femoris as a treatment for fixed knee flexion deformity in cerebral palsy. / Tenotomía intrapélvica del psoas y alargamiento proximal del recto anterior como tratamiento del flexo fijo de rodilla en parálisis cerebral infantil.

Although the correction of knee flexion by lengthening the hamstring musculature is traditionally contemplated in cerebral palsy, literature suggests that treatment of hip flexion also improves knee extension. The aim of the study was to first show the efficacy of the sequence of intrapelvic tenotomy of the psoas followed by intramuscular lengthening of the proximal rectus anterior and, later, that of both surgical soft tissue surgeries separately. For this, a prospective study was carried out in 10 patients with a mean age of 14 years, which presented 16 fixed knee flexes with a mean of deformity of 22°. The data was analyzed through means of an ANOVA of repeated measures and to determine the effect separately of each one of the techniques, the improvements obtained with respect to the previous level were contrasted. The mean extension achieved was 12°, 7° corresponding to the intrapelvic tenotomy of the psoas and, on the remaining knee flexion, a correction of 5° after intramuscular lengthening of the anterior rectus at the proximal level. Both the sequence of proposed gestures and those that form separately, showed statistically significant differences (P <0.001) in the correction of the deformity. In conclusion, the proposed techniques applied sequentially or separately are effective in reducing knee flexion in predominantly spastic cerebral palsy, facilitating or even being able to avoid the treatment that is directly needed.

[Evaluation of function and limiting factors of gait disorder treatment in cerebral palsy: development of the Walking Abilities Levels Classification System]. / Evaluación funcional y de factores limitantes del tratamiento de los trastornos de la marcha en la parálisis cerebral infantil: desarrollo del sistema de clasificación de niveles de deambulación funcional.

INTRODUCTION: The Gross Motor Function Classification System has allowed us to stratificate cerebral palsy patients, according to their walking abilities. The lack of sensitivity about detecting changes and the absence of a global patient evaluation, justify the search of new pre-operative evaluation tools. AIMS: To present the Walking Abilities Levels Classification System (WALCS) and to show the first inter-observer agreement study that has been carried out. This system uses first a different pattern for ordering gait functional skills, and after that, evaluates the reversibility of the contextual factors that may limit the result of a gait disorder treatment. SUBJECTS AND METHODS: A new evaluation frame was built by an interdisciplinary team with an average professional experience of more than 15 years, initially focused as part of the pre-surgical patient evaluation. An inter-observer agreement study was held to gain the first insight of it. 14 participants studied the medical reports and gait lab video images of 10 cases. RESULTS: The kappa index was 0.76 for the walking ability level, 0.79 for the biological type, 0.69 psychological type and 0.64 social type of limiting factors. CONCLUSIONS: The WALCS offers a new evaluation frame gathering patient walking skills and limiting factors treatment. The initial inter-observer agreement rate endorsed more intra- and inter-studies in order to achieve a more robust validation.

TITLE: Evaluación funcional y de factores limitantes del tratamiento de los trastornos de la marcha en la parálisis cerebral infantil: desarrollo del sistema de clasificación de niveles de deambulación funcional.Introducción. El Gross Motor Function Classification System ha permitido estratificar, según su habilidad para caminar, a los pacientes que padecen parálisis cerebral infantil. La falta de sensibilidad en la detección de cambios y la ausencia de una evaluación del paciente en el contexto en el que se encuentra justifican la búsqueda de alternativas de evaluación pretratamiento. Objetivos. Presentar y mostrar la concordancia interobservador inicial del sistema de clasificación de niveles de deambulación funcional. Con él se evalúa la destreza para caminar y la necesidad de asistencia para realizar transferencias desde la silla de ruedas, y, posteriormente se analiza el escenario que la salud y el entorno del paciente ofrecen como condicionantes en la corrección de la marcha o la bipedestación asistida. Sujetos y métodos. Se describe un nuevo marco de evaluación, elaborado por un grupo interdisciplinar con más de 15 años de experiencia media, enfocado inicialmente a la toma de decisiones antes de un tratamiento quirúrgico. Como control interno, 14 participantes evaluaron la historia clínica y los vídeos de marcha de 10 casos. Resultados. Se alcanzó un índice kappa de acuerdo de 0,76 en niveles funcionales y de 0,79 en el tipo de escenario biológico, de 0,69 en el psicológico y de 0,64 en el social. Conclusiones. El sistema de clasificación de niveles de deambulación funcional ofrece un marco para la evaluación conjunta de la deambulación y de los factores limitantes en la eficacia de un tratamiento. La concordancia interobservador avala iniciar su validación.