Baseline patient reported outcome measurement information system (PROMIS) scores in children with idiopathic scoliosis and their relation to the SRS-22.

PURPOSE: PROMIS is becoming the most commonly utilized patient-reported outcome measure (PROM) in adult orthopaedics, but its adoption has lagged in pediatrics. Limited baseline data exists in pediatric-specific orthopaedic diagnoses. The objective of this study was to determine baseline PROMIS scores in patients with idiopathic scoliosis and to evaluate for correlations with the SRS-22. METHODS: This was a retrospective analysis of prospectively collected data from six tertiary care pediatric hospitals between July 2016 and July 2018. Patients with a diagnosis of idiopathic scoliosis, adequate radiographs for measurement and completion of PROMIS and SRS-22 questionnaires from the same visit were included. Only the first visit during the study period was included for each subject. Post-operative patients were excluded. Spearman correlations were performed between four PROMIS domains (Pain interference [PI], Mobility [M], Peer Relationships [PR] and Upper Extremity [UE]) and SRS-22 domains. PROMIS scores are calibrated such that 50 is the median value in a population and 10 points is equivalent to one standard deviation. RESULTS: 986 patients with a mean age of 14.6 years were included, 79.8% of which were female. The mean major curve was 33.0° (range: 10-102). The major curve was thoracic in 56.5%, thoracolumbar in 24.4% and lumbar in 19.1% of subjects. The mean PROMIS domain scores were: Pain Interference 44.5 (IQR 17.7); Mobility 52.7 (IQR 12.5); Peer Relationships 55.7 (IQR 15.0); Upper Extremity 53.4 (IQR 7.7). Correlations existed between PROMIS Pain Interference and SRS-22 pain (r = 0.704, p < 0.001) and PROMIS Mobility and SRS-22 function (r = 0.53, p < 0.001). Significant ceiling effects existed in SRS-22 Function (29.9%), Pain (19.2%) and Satisfaction (30.3%) but only for PROMIS Peer Relationships (42.1%). CONCLUSIONS: PROMIS domain scores for patients with AIS are within normal population limits. PROMIS correlates well with SRS-22 in overlapping domains, and fewer domains demonstrate a ceiling effect. There was no relationship between the magnitude of scoliosis and PROMIS domain scores. LEVEL OF EVIDENCE: II.

Adults with cerebral palsy rank factors associated with quality of life and perceived impact of childhood surgery on adult outcomes.

BACKGROUND: Person-centered care concerns the values and perceptions of the patient in assessment of outcomes. Little is known about perceptions of adults with cerebral palsy (CP) concerning: the most important factors associated with quality of life, definitions of success, short- and long-term outcomes of childhood orthopedic care, and current needs for information surrounding childhood orthopedic care. METHODS: An online survey gathered information using structured and semi-structured questions. Descriptive statistics and content analysis summarized findings of structured questions and comments. RESULTS: A total of 71 adults with CP (44 women, median age range 30-39 years), with a variety of functional abilities, participated in the study. Priorities for a good life were clustered. There existed two groups: achievement orientation and relationship orientation. Good health and interpersonal relationships were priorities for both groups. Definitions of success included happiness, independence, meaningful relationships/activities, and mindfulness/lifelong-learning. Fifty-eight percent perceived a positive impact of childhood orthopedic care on current function. A positive perception was associated with being included in the decision making process (chi-square 25, p < .001). Suggestions to improve childhood orthopedic care included: more information about long-term outcomes, surgical timing, and alternatives to surgery, and improved service delivery models to prevent gaps in care across the lifespan. CONCLUSION: Ongoing conversations about how improvements from orthopedic surgery in childhood may not last through adolescence or adulthood are needed. The importance of impairment-based interventions should be contextualized within needs for health promotion and social engagement long-term. More research is needed on cost-benefit of childhood orthopedic surgery.Implications for RehabilitationPerceptions of being included in decisions about surgery as a child was associated with long term satisfaction.Consumer education is needed about how improvements gained in childhood may not persist through adolescence or into adulthood.Individual priorities for quality of life vary; and these priorities should be considered when weighing the cost benefit ratio of interventions.Clinicians should broaden the conversation to include how orthopedic surgery and rehabilitation afterwards could potentially impact health and well being in the future.

Increased acute postoperative wound problems following spinal fusion in overweight patients with adolescent idiopathic scoliosis.

This study assessed the rate of adverse wound events in individuals with adolescent idiopathic scoliosis who underwent a posterior spinal fusion and sought to determine if obesity was related to the rate of adverse wound events. A retrospective review of patients with adolescent idiopathic scoliosis that underwent posterior spinal fusion between 2001 and 2013 was performed. Preoperative, perioperative, and postoperative data, including wound adverse events, were obtained through medical record review. Using the Center for Disease Control BMI criteria, participants were grouped into overweight/obese (BMI%≥85 percentile) or healthy/underweight (BMI%<85 percentile) groups. Obesity and prolonged hospital stay were independent risk factors for increased risk of wound problems.

Delay in the Diagnosis of Stable Slipped Capital Femoral Epiphysis.

INTRODUCTION: Delays in the diagnosis of stable slipped capital femoral epiphysis (SCFE) is common due to the vague symptomatology and the lack of awareness of this entity by healthcare providers. Delays in the diagnosis of this condition can lead to poor outcomes for the patients. This study was designed to identify factors that contributed to delays in the diagnosis or the treatment of patients with SCFE seen at our institution. METHODS: A retrospective chart review of patients with the diagnosis of a stable SCFE who had undergone screw stabilization between 1989 and 2010 at our hospital was performed. For each patient, demographic data, the date of initial onset of symptoms, the date of the first visit to the medical provider, the type of provider seen initially (orthopaedic surgeon or not), the date of diagnosis of SCFE, the type of physician who made the diagnosis (orthopaedic surgeon or not), and the date of surgery were recorded. For each patient, the presenting symptom was recorded as hip, thigh, or knee pain. The effect of demographic data, presenting symptoms, and the type of initial provider seen on the delay to diagnosis was studied using 2 Cox models. RESULTS: A total of 149 patients with 196 stable SCFE were included. The average time from the first physician visit to diagnosis was 94 days in the group seen by a nonorthopaedic provider compared with an average of 2.9 days in the group seen by an orthopaedist (P<0.05). Diagnosis was made in 1 week only in 19% of the group seen by a nonorthopaedic provider versus 97% in the group seen by orthopaedic surgeons. It took significantly longer to be diagnosed with SCFE in patients who presented with initial knee pain (P=0.0097) compared with those who presented with hip pain at the initial visit. CONCLUSIONS: This study shows a significant delay in the diagnosis of SCFE in the United States, particularly in patients seen by nonorthopaedic providers initially. LEVEL OF EVIDENCE: Level III-prognostic.

Variation in kinematic and spatiotemporal gait parameters by Gross Motor Function Classification System level in children and adolescents with cerebral palsy.

AIM: The aim of this study was to examine differences in gait kinematics and spatiotemporal parameters in ambulatory children and adolescents with bilateral spastic cerebral palsy (BSCP) among Gross Motor Function Classification System (GMFCS) levels I-III. METHOD: A retrospective review was conducted of individuals with BSCP who had three-dimensional motion analysis (3DGA) at one of seven pediatric hospitals. Means and standard deviations of each gait parameter were stratified by GMFCS levels (I-III) and for a typically developing comparison group. RESULTS: Data from 292 children and adolescents with BSCP (189 males, 103 females; mean age 13 y) were compared to a typically developing comparison group (24 male, 26 female; mean age 10 y 6 mo). Gait patterns differed from typically developing in all GMFCS levels, with increasing deviation as GMFCS level increased in 21 out of 28 parameters. Despite significant differences in selected mean kinematic parameters among GMFCS levels such as knee angle at initial contact of 24°, 29°, and 41° in GMFCS levels I, II and III respectively, there was also substantial overlap among GMFCS levels. INTERPRETATION: GMFCS levels cannot be identified using specific gait kinematics. Treatment decisions should be guided by comprehensive 3DGA that allows measurement of gait impairments at the joint level for each individual.

Relationship of Strength, Weight, Age, and Function in Ambulatory Children With Cerebral Palsy.

BACKGROUND: The natural history of ambulatory function in individuals with cerebral palsy (CP) consists of deterioration over time. This is thought to be due, in part, to the relationship between strength and weight, which is postulated to become less favorable for ambulation with age. METHODS: The study design was prospective, case series of 255 subjects, aged 8 to 19 years, with diplegic type of CP. The data analyzed for the study were cross-sectional. Linear regression was used to predict the rate of change in lower extremity muscle strength, body weight, and strength normalized to weight (STR-N) with age. The cohort was analyzed as a whole and in groups based on functional impairment as reflected by Gross Motor Function Classification System (GMFCS) level. RESULTS: Strength increased significantly over time for the entire cohort at a rate of 20.83 N/y (P=0.01). Weight increased significantly over time for the entire cohort at a rate of 3.5 kg/y (P<0.0001). Lower extremity STR-N decreased significantly over time for the entire cohort at a rate of 0.84 N/kg/y (P<0.0001). The rate of decline in STR-N (N/kg/y) was comparable among age groups of the children in the study group. There were no significant differences in the rate of decline of STR-N (N/kg/y) among GMFCS levels. There was a 90% chance of independent ambulation (GMFCS levels I and II) when STR-N was 21 N/kg (49% predicted relative to typically developing children). DISCUSSION: The results of this study support the longstanding clinically based observation that STR-N decreases with age in children with CP. This decrease occurs throughout the growing years, and across GMFCS levels I to III. Independent ambulation becomes less likely as STR-N decreases. This information can be used to support the rationale, and provide guidelines, for a range of interventions designed to promote ambulation in children with CP.

Analysis of the relationships that body composition and muscular strength have with oxygen cost of walking in children with cerebral palsy.

OBJECTIVE: To investigate whether body composition and lower extremity strength relate to oxygen cost of walking in children with cerebral palsy (CP), and to evaluate the relative contributions of these measures to explain variation in oxygen cost seen in this population. METHODS: A total of 116 children with spastic diplegic CP, Gross Motor Function Classification System levels I-III, aged 8-18 participated. Strength, body composition (body mass index (BMI) and percent body fat) and oxygen cost were recorded. Pearson correlations assessed relationships between variables of body composition and strength to oxygen cost. Forward stepwise linear regression analyzed variance explained by strength and body composition measures. Oxygen data were analyzed by weight status classifications using one-way analysis of variance with significance set at p<0.05. RESULTS: Total strength (r=-0.27) and total extensor strength (r=-0.27) had fair inverse relationships with oxygen cost. Total extensor strength explained 7.5% (r(2)=0.075, beta=-0.274, p<0.01) of the variance in oxygen cost. Body composition did not explain significant variance in oxygen cost, however significant differences were found in oxygen consumption (p=0.003) and walking velocity (p=0.042) based on BMI weight classifications. CONCLUSIONS: For ambulatory children with CP, oxygen cost during walking can be partially explained by total extensor strength and not body composition. However, those categorized as obese may adjust to a slower walking speed to keep their oxygen cost sustainable, which may further affect their ability to keep up with typically developing peers and possibly lead to greater fatigue.

Variability explained by strength, body composition and gait impairment in activity and participation measures for children with cerebral palsy: a multicentre study.

OBJECTIVE: To determine the amount of variability in scores on activity and participation measures used to assess ambulatory individuals with cerebral palsy explained by strength, body composition, gait impairment and participant characteristics. DESIGN: Multicentre prospective cross-sectional study. SETTING: Seven paediatric-orthopaedic specialty hospitals. PARTICIPANTS: Three hundred and seventy-seven ambulatory individuals (241 males, 136 females) with cerebral palsy, Gross Motor Function Classification System (GMFCS) levels I-III (I = 148, II = 153, III = 76), ages 8-18 years (mean 12 years 9 months, SD 2 years 8 months). METHODS: Participants completed assessments of GMFCS level, patient history, lower extremity muscle strength, Gross Motor Function Measure (GMFM-66), Pediatric Outcomes Data Collection Instrument (PODCI), instrumented gait analysis, 1 minute walk test, Timed Up-and-Go and body composition. Multiple linear regression and bootstrap analyses were performed for each outcome measure, stratified by GMFCS level. RESULTS: The amount of variability in outcome measures explained by participant characteristics, strength, and gait impairment ranged from 11% to 50%. Gait impairment was the most common predictor variable and frequently explained the greatest variance across all outcome measures and GMFCS levels. As gait impairment increased, scores on outcome measures decreased. Strength findings were inconsistent and not a primary factor. Body composition contributed minimally (<4%) in explaining variability. Participant characteristics (cerebral palsy type, gestational age and age at walking onset), were significant predictor variables in several models. CONCLUSIONS: Variability in outcome measure scores is multifaceted and only partially explained by strength and gait impairment illustrating the challenges of attempting to explain variation within this heterogeneous population. Clinicians treating individuals with cerebral palsy should consider this when developing treatment paradigms.

One-Minute Walk and modified Timed Up and Go tests in children with cerebral palsy: performance and minimum clinically important differences.

AIM This prospective multicenter study assessed performance and changes over time, with and without surgical intervention, in the modified Timed Up and Go (mTUG) and One-Minute Walk tests (1MWT) in children with bilateral cerebral palsy (CP). Minimum clinically important differences (MCIDs) were established for these tools. METHOD Two hundred and nineteen participants with bilateral spastic CP (Gross Motor Function Classification System [GMFCS] levels I­III) were evaluated at baseline and 12 months follow-up. The non-surgical group (n=168; 54 females, 114 males; mean age 12y 11mo, [SD 2y 7mo], range 8y 1mo­19y) had no surgical interventions during the study. The surgical group (n=51; 19 females, 32 males; mean age 12y 10mo [SD 2y 8mo] range 8y 2mo­17y 5mo) underwent soft-tissue and/or bony procedures within 12 months from baseline. The mTUG and 1MWT were collected and MCIDs were established from the change scores of the non-surgical group. RESULTS Dependent walkers (GMFCS level III) required more time to complete the mTUG (p≤0.01) than independent walkers (GMFCS levels I and II). For the 1MWT, distance walked decreased with increasing impairment (p≤0.01). 1MWT and mTUG change scores were not significantly different at any GMFCS level for either the surgical or non-surgical groups (p≤0.01). INTERPRETATION Children with varying levels of function (GMFCS level) perform differently on the 1MWT and mTUG. The data and MCID values can assist clinicians in interpreting changes over time and in assessing interventions.

Accuracy of skinfold and bioelectrical impedance assessments of body fat percentage in ambulatory individuals with cerebral palsy.

AIM: This study assessed the accuracy of measurements of body fat percentage in ambulatory individuals with cerebral palsy (CP) from bioelectrical impedance analysis (BIA) and skinfold equations. METHOD: One hundred and twenty-eight individuals (65 males, 63 females; mean age 12y, SD 3, range 6-18y) with CP (Gross Motor Function Classification System [GMFCS] levels I (n=6), II (n=46), and III (n=19) participated. Body fat percentage was estimated from (1) BIA using standing height and estimated heights (knee height and tibial length) and (2) triceps and subscapular skinfolds using standard and CP-specific equations. All estimates of body fat percentage were compared with body fat percentage from dual-energy X-ray absorptiometry (DXA) scans. Differences between DXA, BIA, and skinfold body fat percentage were analyzed by comparing mean differences. Agreement was assessed by Bland-Altman plots and concordance correlation coefficients (CCC). RESULTS: BMI was moderately correlated with DXA (Pearson's r=0.53). BIA body fat percentage was significantly different from DXA when using estimated heights (95% confidence intervals [CIs] do not contain 0) but not standing height (95% CI -1.9 to 0.4). CCCs for all BIA comparisons indicated good to excellent agreement (0.75-0.82) with DXA. Body fat percentage from skinfold measurements and CP-specific equations was not significantly different from DXA (mean 0.8%; SD 5.3%; 95% CI -0.2 to 1.7) and demonstrated strong agreement with DXA (CCC 0.86). INTERPRETATION: Accurate measures of body fat percentage can be obtained using BIA and two skinfold measurements (CP-specific equations) in ambulatory individuals with CP. These findings should encourage assessments of body fat in clinical and research practices.

Generation, absorption, and transfer of mechanical energy during walking in children.

The purpose of this study was to characterize the manner in which net joint moments and non-muscular forces generate, absorb, and transfer mechanical energy during walking in able-bodied children. Standard gait data from seven healthy subjects between 6 and 17 years of age were combined with a dynamic model of the whole body to perform a power analysis based on induced acceleration techniques. These data were used to determine how each moment and force generates energy to, absorbs energy from, and transfers energy among the major body segments. The joint moments were found to induce transfers of mechanical energy between body segments that generally exceeded the magnitudes of energy generation and absorption. The amount of energy transferred by gravitational and velocity-dependent forces was considerably less than for the joint moments. The hip and ankle joint moments had relatively simple power patterns that tended to oppose each other, particularly over the stance phase. The knee joint moment had a more complex power pattern that appeared distinct from the hip and ankle moments. The general patterns of mechanical energy flow were similar to previous reports in adults. The approach described in this paper should provide a useful complement to standard clinical gait analysis procedures.

Determinants of intensity of participation in leisure and recreational activities by youth with cerebral palsy.

OBJECTIVE: To test a model of determinants of intensity of participation in leisure and recreational activities by youth with cerebral palsy (CP). DESIGN: Prospective cohort study. SETTING: Children's hospitals (N=7). PARTICIPANTS: Youth with CP (N=205; age, 13-21y) and their parents. The sample included 107 (57.2%) males and 26 (12.7%) to 57 (27.8%) youth in each of the 5 levels of the Gross Motor Function Classification System (GMFCS). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Youth completed the Children's Assessment of Participation and Enjoyment by means of an interview. Parents completed the Pediatric Outcomes Data Collection Instrument, Family Environment Scale, Coping Inventory, Measure of Processes of Care, a demographic questionnaire, and a services questionnaire. RESULTS: Structural equation modeling was used to test the model. Fit statistics indicate good model fit. The model explains 35% of the variance in intensity of participation. Path coefficients (P ≤ .05) indicate that higher physical ability, higher enjoyment, younger age, female sex, and higher family activity orientation are associated with higher intensity of participation. GMFCS level and caregiver education have indirect effects on intensity of participation. The path between services and intensity of participation was not significant. CONCLUSIONS: Participation by youth with CP is influenced by multiple factors. The influence of physical activity supports the importance of activity accommodations and assistive technology for youth who are not capable of improving physical ability. Knowledge of family activity orientation is important for identifying opportunities for participation. The unexplained variance suggests that the model should include other determinants, such as physical accessibility and availability of transportation and community leisure and recreational activities.

Determinants of intensity of participation in leisure and recreational activities by children with cerebral palsy.

AIM: To test a model of child, family, and service determinants of intensity of participation in leisure and recreational activities by children with cerebral palsy (CP). METHOD: Participants were 288 children with CP, age range 6 to 12 years (mean 9y 8mo, SD 2y), and their parents from seven children's hospitals. The sample comprised 166 (57.6%) males and 122 (42.4%) females, and between 40 (13.9%) and 74 (25.7%) children in each of the five levels of the Gross Motor Function Classification System. Children completed the Children's Assessment of Participation and Enjoyment by interview. Parents completed the Pediatric Outcomes Data Collection Instrument, Family Environment Scale, Coping Inventory, Measure of Processes of Care, and two questionnaires. Structural equation modeling was used to test the model. RESULTS: Fit statistics indicated a good model fit. The model explains 32% of the variance in intensity of participation. Path coefficients (p ≤ 0.05) indicate that higher gross motor function, higher enjoyment, more effective adaptive behavior, younger age, and higher family activity orientation are associated with higher intensity of participation. The path between services and participation was not significant. INTERPRETATION: Intensity of participation of children with CP is influenced by multiple child and family determinants. Children's gross motor function and behavior in life situations are important for participation; knowledge of activities the child and family enjoy has implications for opportunities for participation. Professionals are encouraged to address priorities for leisure and recreation identified by children with CP and their families.

Tibial length growth curves for ambulatory children and adolescents with cerebral palsy.

AIM: The aim of this study was to generate growth curves for ambulatory children and adolescents with cerebral palsy (CP) using tibial lengths and to determine if they differed according to sex or Gross Motor Function Classification System (GMFCS) level. METHOD: Growth data were studied from a cohort of 750 participants (442 males, 308 females [1199 visits]; mean age 10 y 9 mo, SD 3 y 4 mo, range 4-21 y) with CP (hemiplegia, n=163; diplegia, n=573; triplegia, n=11; quadriplegia n=2; GMFCS levels I-III), and 165 typically developing children (96 males, 115 females; [211 visits]) mean age 10 y 9 mo, SD 4 y 2 mo, range 4-19 y). Tibial length measurements calculated from data collected during routine gait analyses were validated using anthropometric tibial length measurements and were used to generate growth curves for males and females classified as GMFCS level I, II, or III. Growth was compared in participants of different sexes and GMFCS levels using the median curves. RESULTS: Growth curves for males and females (GMFCS levels I-III) with estimate lines for 3rd, 10th, 25th, 50th, 75th, 90th, and 97th centiles were generated. Mean tibial length was greater in males than in females in all GMFCS levels. Tibial lengths were shorter in participants classified as GMFCS level III than in those classified as GMFCS level I or II. INTERPRETATION: To our knowledge this is the first large-scale investigation of bone growth in ambulatory children and adolescents with CP. The large sample made it possible to generate growth curves and to provide insight into growth trends. The study findings serve as a basis for analysis of the relationships between growth, function, and treatment outcomes.

A prospective cohort study of the effects of lower extremity orthopaedic surgery on outcome measures in ambulatory children with cerebral palsy.

BACKGROUND: Lower-extremity musculotendinous surgery is standard treatment for ambulatory children with deformities such as joint contractures and bony torsions resulting from cerebral palsy (CP). However, evidence of efficacy is limited to retrospective, uncontrolled studies with small sample sizes focusing on gait variables and clinical examination measures. The aim of this study was to prospectively examine whether lower-extremity musculotendinous surgery in ambulatory children with CP improves impairments and function measured by gait and clinical outcome tools beyond changes found in a concurrent matched control group. METHODS: Seventy-five children with spastic CP (Gross Motor Function Classification System levels I to III, age 4 to 18 y) that underwent surgery to improve gait were individually matched on the basis of sex, Gross Motor Function Classification System level, and CP subtype to a nonsurgical cohort, minimizing differences in age and Gross Motor Function Measure Dimension E. At baseline and at least 12 months after baseline or surgery, participants completed gait analysis and Gross Motor Function Measure, and parents completed outcome questionnaires. Mean changes at follow-up were compared using analysis of covariance adjusted for baseline differences. RESULTS: Surgery ranged from single-level soft tissue release to multilevel bony and/or soft tissue procedures. At follow-up, after correcting for baseline differences, Gillette Gait Index, Pediatric Outcomes Data Collection Instrument Expectations, and Pediatric Quality of Life Inventory (PedsQL) Physical Functioning improved significantly for the surgical group compared with the nonsurgical group, which showed minimal change. CONCLUSIONS: On the basis of a matched concurrent data set, there was significant improvement in function after 1 year for a surgical group compared with a nonsurgical group as measured by the Gillette Gait Index, with few significant changes noted in outcome measures. Changes over 1 year are minimal in the nonsurgical group, supporting the possibility of ethically performing a randomized controlled trial using nonsurgical controls. LEVEL OF EVIDENCE: Therapeutic level 2. Prospective comparative study.

Social and community participation of children and youth with cerebral palsy is associated with age and gross motor function classification.

BACKGROUND: Through social and community participation, children and youth with cerebral palsy (CP) form friendships, gain knowledge, learn skills, express creativity, and determine meaning and purpose in life. OBJECTIVE: The purposes of this study were: (1) to determine whether social and community participation of children and youth with CP differ based on age, sex, and gross motor function, and (2) to identify the types of activities in which social and community participation are highest. DESIGN AND METHODS: A prospective cross-sectional analytic design was used. The participants were a sample of convenience of 291 children (6-12 years of age) and 209 youth (13-21 years of age) with CP (55.4% males, 44.6% females) receiving services from 7 children's hospitals. Participants completed the Children's Assessment of Participation and Enjoyment (CAPE) by structured interview. Gross Motor Function Classification System (GMFCS) level was determined by the researchers. RESULTS: Youth did a higher percentage of activities with friends and others and outside the home than children. Children and youth in level I did a higher percentage of activities with friends and others compared with children and youth in levels II and III and in levels IV and V. Children and youth in level I and in levels IV and V did a higher percentage of activities outside the home than children and youth in levels II and III. Differences were not found between females and males. The percentage of activities done with friends and others and outside the home was highest for physical and skill-based activities. LIMITATIONS: Findings cannot be attributed only to GMFCS level. CONCLUSIONS: The ability to walk without restrictions is desirable for social and community participation. For children and youth with CP who have limitations in mobility, physical therapists have roles as consultants for accessibility, activity accommodations, and assistive technology and as advocates for inclusive environments.

Clinical applications of outcome tools in ambulatory children with cerebral palsy.

This article provides an overview of outcome tools commonly used to assess ambulatory children with cerebral palsy, research findings from a recent large multi-center study, and ways to integrate the research findings into clinical practice. The information presented in this article and in the referenced articles provides information on: outcome tools' discriminatory ability and responsiveness; readily available comparison data on 7 commonly used outcome tools that can be used at the point of care; prediction equations for the Parent report Pediatric Outcomes Data Collection Instrument (PODCI) by age and Gross Motor Function Classification System (GMFCS) level; and minimum clinically important difference thresholds by GMFCS level. This information can help clinicians select the best outcome tools to discriminate among severity levels and avoid ceiling effects. The scores provided allow direct comparisons between a specific patient and a matched cohort, assisting clinicians in the creation of comprehensive and individualized evaluation and management plans. Use of appropriate outcome tools to assess children with cerebral palsy can lead to best practices and reduced costs in the clinical setting.

Outcomes of gastrocnemius-soleus complex lengthening for isolated equinus contracture in children with cerebral palsy.

BACKGROUND: The goal of the gastrocnemius-soleus complex (GSC) lengthenings in children with cerebral palsy (CP) is to achieve a plantigrade foot and normalize kinematics during gait. The study purpose was to evaluate the results of GSC lengthening for isolated equinus contracture in individuals with CP. It was hypothesized that GSC lengthenings would normalize passive ankle range of motion, kinematic, kinetic, and temporal spatial parameters. METHODS: Gait data from 15 able-bodied participants from the laboratory normal database and passive range of motion, kinematic, kinetic, and temporal spatial gait parameters, and oxygen cost were collected and analyzed for 27 individuals with CP (36 limbs) with isolated equinus contracture who received GSC lengthenings. Data were compared between preoperative and postoperative assessments. RESULTS: Mean age at baseline was 11.4 years (+/-3.2 y). Mean time between surgery and postoperative gait analysis was 1.3 years (+/-0.3 y). Passive range of motion measurements were obtained. Kinematic and kinetic data for the hip, knee and ankle, and temporal spatial parameters were obtained from a representative gait trial preoperatively and postoperatively. Paired t tests (P<0.05) determined whether preoperative data differed from postoperative data or from able-bodied data. The passive range of motion at the ankle was improved and normalized postoperatively. Ankle kinematics normalized without compensatory changes occurring at the knee or hip kinematics. Ankle moments and powers become more normal but did not completely normalize. Kinematics and kinetics of the hip and knee were not adversely affected. No changes in the temporal spatial data or oxygen cost occurred postoperatively. CONCLUSIONS: These data support the finding that with appropriate patient selection isolated GSC lengthening does not result in overcorrection. LEVEL OF EVIDENCE: Retrospective comparative study; level 3.