Gait and participation outcomes in adults with cerebral palsy: a series of case studies using mixed methods.

BACKGROUND: There is a paucity of information on long-term outcomes of adults with cerebral palsy (CP) who received orthopedic interventions in childhood. Clinical effectiveness research requires assessment of outcomes that account for personal and environmental factors that may mediate the effects of treatment, in addition to body structures & function, activity, and participation. OBJECTIVE/HYPOTHESIS: The purpose of this study is to provide a descriptive analysis of characteristics associated with gait and participation outcomes in a series of case studies of adults with CP. METHODS: Participants had follow up gait analysis and clinical evaluation in adulthood and assessment of outcomes with the FIM instrument, the SF-36 Health survey, the Canadian Occupational Performance Measure, and semi-structured questions. RESULTS: Twenty-two out of 26 participants (mean age = 25 years; GMFCS level I (n = 9); II (n = 3); III (n = 11); IV (n = 3)) maintained or improved childhood gait abilities, with levels of participation in society similar to age matched peers. Higher level of severity and personal choices impacted gait abilities in the four who declined. Majority of participants lost range of motion in hip flexion and knee extension, had pain, reported a fitness program, and increased in weight status. Personal factors and environmental factors played a role in both gait and participation outcomes. CONCLUSION: Promotion of fitness activities and social advocacy are warranted for adults with CP. Clinical effectiveness research of long-term impact of orthopedic interventions should account for treatment effects on body structures & function, activity, participation, and modifying effects of personal, and environmental factors.

Walking abilities of young adults with cerebral palsy: changes after multilevel surgery and adolescence.

Although there is some evidence to support the efficacy of single event multilevel surgery (SEMLS) in the short term for improving walking abilities in children with cerebral palsy (CP), long term effects are not known. It is hypothesized: (1) SEMLS improves walking abilities; (2) in young adulthood abilities deteriorate beyond pre-operative status; (3) walking abilities deteriorate from adolescence to young adulthood and are associated with weight status increase. Twenty-three young adults (mean age 25.5 years, range 20-36) with spastic CP Gross Motor Functional Classification Scale Level II (n=11) or III (n=12) returned for follow up three dimensional gait analysis (3DGA). Gillette Gait Index (GGI) was used as a general indicator of walking abilities. Eleven subjects had 3DGA prior to multilevel orthopedic surgery and 12 subjects had 3DGA after the age of 10 with no interventions in the interim. GGI(s) were graphed over time. Ten of 11 subjects (91%) who had multilevel surgery either improved (n=6) or maintained pre-operative walking abilities (n=4) based on GGI. Ten of 12 subjects (83%) who had 3DGA after the age of 10 but no interventions in the interim maintained (n=8) or improved (n=2) walking abilities. No associations were found between declines in walking abilities and increased weight status. After SEMLS, walking abilities in young adulthood were comparable to pre-operative status. A decline in walking abilities was not observed from adolescence to young adulthood.

Changes in gait velocity, mean knee flexion in stance, body mass index, and popliteal angle with age in ambulatory children with cerebral palsy.

BACKGROUND: The purpose of this study was to explore changes in body mass index (BMI), gait velocity, mean knee flexion in stance, and popliteal angle with age in ambulatory children with cerebral palsy. METHODS: A cross-sectional sample of 188 ambulatory children with cerebral palsy Gross Motor Function Classification System II or III who had a motion analysis evaluation. Subjects had no previous surgical interventions and were between the ages of 4 and 21. Velocity was normalized to limb length, and BMI was converted to age-adjusted percentile scores (BMI-a). RESULTS: For GMFCS level II children, age and normalized velocity demonstrated a moderate and significant relationship (r = -0.4; P = 0.000). Age explained 20% of the variance in normalized velocity (P = 0.000). Weak but significant relationships were found between mean knee flexion in stance and normalized velocity (r = -0.3; P = 0.000) and popliteal angle and age (r = 0.3; P < 0.002). For GMFCS level III children, the following variables demonstrated a weak but significant association: normalized velocity and BMI-a (r = 0.3; P < 0.006), popliteal angle, and mean knee flexion in stance (r = 0.3; P < 0.022). Age was not associated with velocity, mean knee flexion in stance, BMI-a, or popliteal angle. CONCLUSIONS: For GMFCS level II children, as age increases, there is a slight decrease in normalized velocity, and with decreasing normalized velocity, there is slightly increased mean knee flexion in stance. For GMFCS level III children, age was not associated with slower velocities, increased mean knee flexion in stance, or increased popliteal angle. Increased BMI-a was not associated with slower gait velocities or increased mean knee flexion in stance. Increasing BMI-a was not associated with increasing age.

Postoperative gait velocity and mean knee flexion in stance of ambulatory children with spastic diplegia four years or more after multilevel surgery.

Factors associated with longer-term outcomes of multilevel orthopaedic surgery in ambulatory children with cerebral palsy using a multivariate approach were evaluated using a retrospective pretest-posttest design. The population included 20 ambulatory children with spastic diplegia who had undergone multilevel orthopaedic surgery with a minimum of 4-year interval between a preoperative and a postoperative gait assessment. Multiple regression analysis was used to identify factors associated with postoperative velocity and mean knee flexion in stance. Independent variables included in the regression models were velocity, mean knee flexion in stance, age at preoperative evaluation, Gross Motor Function Classification System level, use of ankle-foot orthoses, leg length, age-adjusted body mass index, number of surgical procedures, and range of motion of hip and knee. Children who demonstrated faster postoperative gait velocity 4 years or more after surgery were younger at the time of initial evaluation, had undergone fewer surgical procedures, had faster preoperative gait velocity, used ankle-foot orthoses postoperatively, and had increased hip extension range of motion postoperatively (R = 0.55). Children who demonstrated greater knee flexion in stance 4 years or more after surgery had undergone more surgical procedures, greater postoperative popliteal angle, and less knee extension range of motion (R = 0.73). This study demonstrates the usefulness of a multivariate approach toward understanding and predicting outcomes. The results of this study will provide clinicians and researchers more information about those factors associated with maintained improvements in the longer term and may be useful for treatment planning.