Long-term development of gait after multilevel surgery in children with cerebral palsy: a multicentre cohort study.

AIM: We investigated the long-term efficacy and safety of multilevel surgery (MLS) in ambulatory children with bilateral spastic cerebral palsy (CP). METHOD: Two hundred and thirty-one children were evaluated at short term (1.1y, SD 0.4) and long term (9.1y, SD 3.0) follow-up using clinical examination and gait analysis. MLS was investigated by studying changes in the Gait Profile Score (GPS) referenced to the minimally important clinical difference. RESULTS: Ambulatory children aged 10 years and 7 months (SD 2y 11mo) at MLS in Gross Motor Function Classification System levels I (19), II (144), and III (68) showed a decrease (improvement) in preoperative GPS from 16.3° (SD 4.8) to 11.3° (SD 3.2) at short-term follow-up, an improvement of 5°. At long-term follow-up, GPS was maintained at 11.4° (SD 3.1). Overall, 177 (76.6%) children maintained their improvement in GPS after 9 years. INTERPRETATION: Multilevel surgery is a safe and effective surgical intervention, which leads to a significant improvement in gait kinematics in children with bilateral spastic CP. This study improves our understanding of MLS in the long term and will help to inform families and children when planning for MLS. WHAT THIS PAPER ADDS: Largest study of multilevel surgery (MLS) for children with bilateral spastic cerebral palsy, with longest follow-up. MLS resulted in significant long-term improvements in gait function. Minor adverse events were common, while events requiring intervention were uncommon (4% of children). Thirty-nine per cent of children required additional surgery during follow-up. 'Single-event multilevel surgery' was changed to the more realistic term 'multilevel surgery'.

A Decision Support System to Facilitate Identification of Musculoskeletal Impairments and Propose Recommendations Using Gait Analysis in Children With Cerebral Palsy.

The identification of musculoskeletal impairments from gait analysis in children with cerebral palsy is a complex task, as is formulating (surgical) recommendations. In this paper, we present how we built a decision support system based on gait kinematics, anthropometrics, and physical examination data. The decision support system was trained to learn the association between these data and the list of impairments and recommendations formulated historically by experienced clinicians. Our aim was 2-fold, train a computational model that would be representative of data-based clinical reasoning in our center, and support new or junior clinicians by providing pre-processed impairments and recommendations with the associated supportive evidence. We present some of the challenges we faced, such as the issues of dimensionality reduction for kinematic data, missing data imputations, class imbalance and choosing an appropriate model evaluation metric. Most models, i.e., one model for each impairments and recommendations, achieved a weighted Brier score lower than 0.20, and sensitivity and specificity greater than 0.70 and 0.80, respectively. The results of the models are accessible through a web-based application which displays the probability predictions as well as the (up to) 5 best predictors.

Quantifying sources of variability in gait analysis.

Measurements from gait analysis are affected by many sources of variability. Schwartz et al. [1] illustrated an experimental design and methods to estimate these variance components. However, the derivation contains errors which could severely bias the estimation of some components. Therefore, in this paper, we presented correction to this method using ANOVA and Likelihood methods. Furthermore, we demonstrated how commonly used reliability indices like CMC and ICC may be derived from the variance components. We advocate the use of the variance components, in preference to reliability indices, because the variance components are easier to interpret, with understandable units.

Undesirable properties of the dimensionless normalisation for spatio-temporal variables.

We used theory and empirical data to demonstrate three undesirable properties of the dimensionless normalisation technique for gait spatio-temporal parameters. Firstly, it may not fully remove the correlation between leg length and spatio-temporal parameters. Secondly, it induces spurious correlation among spatio-temporal parameters, which might obscure their true correlation structure. Thirdly, it induces spurious correlation with external covariates, which complicates further statistical modelling. Therefore, depending on the objectives, we propose alternatives. If the objective is to compare datasets but remove the confounding effect of leg length, residualisation may be an alternative, although the generalisability of the residualisation is less well established than dimensionless normalisation. If the objective is to build a regression model, the raw spatio-temporal parameters could be used with leg length, or a function of leg length, as an explicit regressor to avoid spurious correlation. If correlation is the objective, partial correlation can be used instead.

Adequacy of laser diffraction for soil particle size analysis.

Sedimentation has been a standard methodology for particle size analysis since the early 1900s. In recent years laser diffraction is beginning to replace sedimentation as the prefered technique in some industries, such as marine sediment analysis. However, for the particle size analysis of soils, which have a diverse range of both particle size and shape, laser diffraction still requires evaluation of its reliability. In this study, the sedimentation based sieve plummet balance method and the laser diffraction method were used to measure the particle size distribution of 22 soil samples representing four contrasting Australian Soil Orders. Initially, a precise wet riffling methodology was developed capable of obtaining representative samples within the recommended obscuration range for laser diffraction. It was found that repeatable results were obtained even if measurements were made at the extreme ends of the manufacturer's recommended obscuration range. Results from statistical analysis suggested that the use of sample pretreatment to remove soil organic carbon (and possible traces of calcium-carbonate content) made minor differences to the laser diffraction particle size distributions compared to no pretreatment. These differences were found to be marginally statistically significant in the Podosol topsoil and Vertosol subsoil. There are well known reasons why sedimentation methods may be considered to 'overestimate' plate-like clay particles, while laser diffraction will 'underestimate' the proportion of clay particles. In this study we used Lin's concordance correlation coefficient to determine the equivalence of laser diffraction and sieve plummet balance results. The results suggested that the laser diffraction equivalent thresholds corresponding to the sieve plummet balance cumulative particle sizes of < 2 µm, < 20 µm, and < 200 µm, were < 9 µm, < 26 µm, < 275 µm respectively. The many advantages of laser diffraction for soil particle size analysis, and the empirical results of this study, suggest that deployment of laser diffraction as a standard test procedure can provide reliable results, provided consistent sample preparation is used.