An Analysis of Relative Gait Impairment in Commonly Diagnosed Pediatric Conditions.

BACKGROUND: Gait indices were developed to represent the magnitude of impairment extracted from a gait analysis with a single value. The Gillette Gait Index (GGI), and the Gait Deviation Index (GDI) are 2 widely used indices that represent gait impairment differently based on their statistical properties. Our purpose was to (1) report on the results of gait analysis for a broad spectrum of pediatric conditions using the GGI and GDI, and (2) identify the parameters that dominate impairment. METHODS: A total of 1439 children with 13 different diagnoses with a complete, baseline gait analysis were identified. The GGI and its 16 parameters were calculated in all cases, and the GDI was calculated from a smaller subset. T tests, and z-scores were used to compare each of these values to typically developing children for each diagnosis. A separate linear regression controlling for age, sex, and use of an orthosis, or assistive device was performed for the GGI. RESULTS: In our series, there were 71 typically developing children with a GGI of 31. We qualify relative gait impairment as severe, mild, or moderate as based on the GGI, and propose that values <100 represent mild, 100 to 200 represent moderate, and >200 represents severe impairment. On the basis of strong correlation between the GGI and GDI, we suggest that GDI values >80 represent mild, and values <70 represent severe impairment. T tests and z-scores demonstrated that both the number and magnitude of abnormal parameters increase the GGI. These tests also identified the most clinically relevant parameters contributing to functional impairment for each diagnosis. Multivariate linear regression showed that all diagnoses except flatfoot and scoliosis demonstrated statistically significant differences in GGI scores. CONCLUSIONS: This is the first study to apply these gait indices to a large population of diverse pediatric conditions. We propose GGI and GDI values to qualify gait impairment among these conditions as severe, moderate, or mild. Furthermore, impairment in gait reflects both the number and magnitude of abnormal parameters within each condition. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

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.

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.

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.

Policy brief: adaptive cycling equipment for individuals with neurodevelopmental disabilities as durable medical equipment.

- Durable medical equipment (DME) policies require that the equipment be medically necessary; however, adaptive cycling equipment (bicycles and tricycles) are usually not deemed medically necessary. - Individuals with neurodevelopmental disabilities (NDD) are at high risk for secondary conditions, both physical and mental, that can be mitigated by increasing physical activity. - Significant financial costs are associated with the management of secondary conditions. - Adaptive cycling can provide improved physical health of individuals with NDD potentially reducing costs of comorbidities. - Expanding DME policies to include adaptive cycling equipment for qualifying individuals with NDD can increase access to equipment. - Regulations to ensure eligibility, proper fitting, prescription, and training can optimize health and wellbeing. - Programs for recycling or repurposing of equipment are warranted to optimize resources.

Rasch analysis of items from two self-report measures of motor function: determination of item difficulty and relationships with children's ability levels.

AIM: The aim of this article was to determine item measurement properties of a set of items selected from the Gillette Functional Assessment Questionnaire (FAQ) and the Pediatric Outcome Data Collection Instrument (PODCI) using Rasch analysis, and to explore relationships between the FAQ/PODCI combined set of items, FAQ walking scale level, Gross Motor Function Classification System (GMFCS) levels, and the Gait Deviation Index on a common measurement scale. METHOD: Rasch analysis was performed on data from a retrospective chart review of parent-reported FAQ and PODCI data from 485 individuals (273 males; 212 females; mean age 9 y 10 mo, SD 3 y 10 mo) who underwent first-time three-dimensional gait analysis. Of the 485 individuals, 289 had a diagnosis of cerebral palsy (104 GMFCS level I, 97 GMFCS level II, 69 GMFCS level III, and 19 GMFCS level IV). Rasch-based person abilities and item difficulties based on subgroups defined by the FAQ walking scale level, Gait Deviation Index, and the GMFCS level were compared. RESULTS: The FAQ/PODCI item set demonstrated necessary Rasch characteristics to support its use as a combined measurement scale. Item groupings at similar difficulty levels were consistent with the mean person abilities of subgroups based on FAQ walking scale level, Gait Deviation Index, and GMFCS level. INTERPRETATION: Rasch-derived person ability scores from the FAQ/PODCI combined item set are consistent with clinical measures. Rasch analysis provides insights that may improve interpretation of the difficulty of motor functions for children with disabilities.

Factor- and item-level analyses of the 38-item activities scale for kids-performance.

AIM: Children and adolescents highly value their ability to participate in relevant daily life and recreational activities. The Activities Scale for Kids-performance (ASKp) instrument measures the frequency of performance of 30 common childhood activities, and has been shown to be valid and reliable. A revised and expanded 38-item ASKp (ASKp38) version has been reported in recent literature and is currently used in clinical research. The aim of this paper is to assess the factor structure and item-level statistics of the ASKp38. METHOD: Our study used factor analyses and Rasch analyses to determine the item-set dimensionality and to calculate item-level statistics respectively, for existing ASKp38 data from 200 children (104 males; 96 females; mean age 12y 7mo; SD 2y 8mo; range 6-20y) with physical disabilities. The children had a variety of physical impairments including cerebral palsy (n = 105; range 8-13 y), limb salvage (n = 18; range 11-20y), arthrogryposis (n = 13; 6-17y), and other, including individuals with spina bifida and spinal cord injury (n = 64; 8-19 y). RESULTS: A two-factor model, with components of activities of daily living and play, most optimally fit the data. Item-fit statistics based on this two-factor model demonstrated adequate fit and content coverage. INTERPRETATION: The ASKp38 appears to consist of two factors, defined as (1) activities of daily living and (2) play, and may be used to measure the frequency of activity performance on two corresponding subscales.

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.

Gillette Functional Assessment Questionnaire 22-item skill set: factor and Rasch analyses.

AIM: To determine dimensionality and item-level properties of the Gillette Functional Assessment Questionnaire (FAQ) 22-item skill set using factor and Rasch analyses. METHOD: A retrospective review of parent-reported FAQ 22-item skill set data was conducted of 485 individuals (273 males, 212 females; mean age 9 y 10 mo, SD 3 y 10 mo), including 289 with cerebral palsy and 196 with a variety of other neuromusculoskeletal conditions with orthopedic impairments. Factor analyses to validate unidimensionality of the skill set and Rasch analyses to determine relative item difficulty, item and test level information, and content coverage of the item set were performed. Differential item functioning analysis of sub-groups based on sex, diagnosis grouping, and age was conducted. Precision of score estimates for the item set was analyzed. RESULTS: The FAQ 22-item skill set demonstrates unidimensional structure and good item fit statistics. No floor or ceiling effects were noted. Differential item functioning (DIF) based on age was noted for seven items, four items showed diagnosis group-related DIF, and one item sex-related DIF. Precision was adequate in the mid-range range of abilities. INTERPRETATION: Based on this analysis, the FAQ 22-item skill set is a hierarchical set of interval scaled items suitable for measuring locomotor skill ability in children.

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.

Content range and precision of a computer adaptive test of upper extremity function for children with cerebral palsy.

This article reports on the content range and measurement precision of an upper extremity (UE) computer adaptive testing (CAT) platform of physical function in children with cerebral palsy. Upper extremity items representing skills of all abilities were administered to 305 parents. These responses were compared with two traditional standardized measures: Pediatric Outcomes Data Collection Instrument and Functional Independence Measure for Children. The UE CAT correlated strongly with the upper extremity component of these measures and had greater precision when describing individual functional ability. The UE item bank has wider range with items populating the lower end of the ability spectrum. This new UE item bank and CAT have the capability to quickly assess children of all ages and abilities with good precision and, most importantly, with items that are meaningful and appropriate for their age and level of physical function.

Precision and content range of a parent-reported item bank assessing lower extremity and mobility skills in children with cerebral palsy.

AIM: The aim of this study was to determine the psychometric properties, content range, and measurement precision of a lower extremity physical functioning and mobility skills item bank (LE85) in children with cerebral palsy (CP). METHOD: Lower extremity functioning and mobility skill items were administered to 308 parents of children (169 males, 139 females; mean age 10y 8mo, SD 4y) with spastic CP (145 diplegia, 73 hemiplegia, 89 quadriplegia; [for one person type of CP was unknown]) classified using the Gross Motor Function Classification System (75 level I, 91 level II, 79 level III, 37 level IV, 26 level V). Additional legacy measures were administered to assess concurrent validity. Psychometric characteristics, differential item functioning, content range, and score precision were examined. RESULTS: The LE85 had acceptable psychometric properties. Content range matched the ability range of the sample population and exceeded legacy measures with minimal differential item functioning. The LE85 had good correlation with the Paediatric Outcomes Data Collection Instrument, Functional Independence Measure for Children, Gillette Functional Assessment Questionnaire, and Paediatric Quality of Life Inventory-CP module (range r=0.63-0.86). Precision of the LE85 and 10-item simulated computer adaptive test scores outperformed legacy measures. INTERPRETATION: The LE85 appears to be suitable to administer as a computer adaptive test to measure lower extremity physical functioning and mobility in children with CP.

Validity and reliability of physical functioning computer-adaptive tests for children with cerebral palsy.

BACKGROUND: The purpose of this study was to assess the concurrent validity and reliability of scores from 4 new parent-report computer-adapted testing (CAT) programs developed to measure the physical functioning of children with cerebral palsy (CP). The Shriners Hospitals for Children CP-CAT battery includes upper-extremity skills, lower-extremity and mobility skills, activity, and global physical health. METHODS: This was a prospective study of 91 children with CP who were tested cross-sectionally and 27 children with CP who were administered the CP-CAT programs twice within approximately a 1-month interval. We examined the concurrent validity of the 4 Shriners Hospitals for Children CP-CAT programs by Pearson correlations with comparative parent-report instruments. The scale reliability was tested by developing estimates of marginal reliability; test-retest reliability was assessed by intraclass correlations. RESULTS: Pearson correlations were moderate to high in matching content domains of the CATs with the comparison measures. Marginal reliability estimates were always better for the CAT program than the comparative instruments. Average test-retest reliability using Intraclass correlations across the 4 CATs was ICC3,1=0.91 with a range of 0.88 to 0.94. CONCLUSIONS: We found the CAT scores to be related to expected domains from external instruments, to have good scale reliability, and to have stable scores as determined by test-retest reliability. These results support the use of parent-report CATs in the assessment of physical functioning in children with CP.

Clinical efficacy of instrumented gait analysis: Systematic review 2020 update.

BACKGROUND: This paper updates our 2011 systematic review on the clinical efficacy of three-dimensional instrumented gait analysis (3DGA). RESEARCH QUESTION: What is the current evidence base pertaining to the clinical efficacy of 3DGA? METHODS: We identified English language articles published from September 2009 to October 2019 reporting primary research that used typical motion analysis laboratory methods to study human walking. Five gait laboratory experts classified articles according to the highest type of efficacy they addressed: type 1 (technical), 2 (diagnostic accuracy), 2b (outcome prediction), 3-4 (diagnostic thinking and treatment), 5 (patient outcome), 6 (societal). Articles classified into type 3-4 and higher were rated for quality using LEGEND. RESULTS: Of 2712 articles related to the efficacy of 3DGA, over 99% addressed technical (n = 313), diagnostic (n = 1466), or outcome prediction (n = 927) efficacy. Six type 3-4 studies showed that 3DGA changes treatment plans, increases clinicians' confidence in their treatment decisions, and increases agreement among clinicians. Two type 5 articles based on a randomized controlled trial demonstrated that patient outcomes improved only when 3DGA data were available and its recommendations were followed. A population-based type 5 study found that the incidence of severe crouch gait dropped from 25% to 4% following practice changes including the addition of 3DGA. The strength of evidence was mainly 3b (lesser quality prospective cohort studies) but also included stronger studies (three level 2 controlled clinical trials). SIGNIFICANCE: Literature related to the clinical efficacy of 3DGA has grown substantially over the last decade. Thousands of articles contribute to continued improvement of data collection and interpretation, as well as understanding of gait pathology and treatment. A smaller number of studies clearly demonstrate the efficacy of 3DGA in changing and reinforcing treatment decisions, increasing clinicians' confidence in treatment planning, and increasing agreement among clinicians, as well as the potential to improve patient outcomes.

Development of a parent-report computer-adaptive test to assess physical functioning in children with cerebral palsy II: upper-extremity skills.

The specific aims of this study were to (1) examine the psychometric properties (unidimensionality, differential item functioning, scale coverage) of an item bank of upper-extremity skills for children and adolescents with cerebral palsy (CP); (2) evaluate a simulated computer-adaptive test (CAT) using this item bank; (3) examine the concurrent validity of the CAT with the Pediatric Outcomes Data Collection Instrument (PODCI) upper-extremity core scale; and (4) determine the discriminant validity of the simulated CAT with Manual Ability Classification System (MACS) levels and CP type (i.e. diplegia, hemiplegia, or quadriplegia). Parents (n=180) of children and adolescents with CP (spastic diplegia 49%, hemiplegia 22%, or quadriplegia 28%) consisting of 102 males and 78 females with a mean age of 10 years 6 months (SD 4y 1mo, range 2-21y), and MACS levels I through V participated in calibration of an item pool and completed the PODCI. Confirmatory factor analyses supported a unidimensional model using 49 of the 53 upper-extremity items. Simulated CATs of 5, 10, and 15 items demonstrated excellent accuracy (intraclass correlation coefficient [ICCs] >0.93) with the full item bank, had high correlations with the PODCI upper-extremity core scale score (ICC 0.79), and discriminated among MACS levels. The simulated CATs demonstrated excellent overall content coverage over a wide age span and severity of upper-extremity involvement. The future development and refinement of CATs for parent report of physical function in children and adolescents with CP is supported by our work.

Development of a parent-report computer-adaptive test to assess physical functioning in children with cerebral palsy I: lower-extremity and mobility skills.

The objective of this project was to develop computer-adaptive tests (CATs) using parent reports of physical function in children and adolescents with cerebral palsy (CP). The specific aims of this study were to (1) examine the psychometric properties of an item bank of lower-extremity and mobility skills for children with CP; (2) evaluate a CAT using this item bank; (3) examine the concurrent validity of the CAT with the Pediatric Outcomes Data Collection Instrument (PODCI) and the Functional Assessment Questionnaire (FAQ); and (4) establish the discriminant validity of simulated CATs with Gross Motor Function Classification System (GMFCS) levels and CP type (diplegia, hemiplegia, or quadriplegia). Parents (n=190) of children and adolescents with spastic diplegic (48%), hemiplegic (22%), or quadriplegic (30%) CP consisting of 108 males and 82 females with a mean age of 10 years 7 months (SD 4y 1mo, range 2-21y) and in GMFCS levels I to V participated in item pool calibration and completed the PODCI and FAQ. Confirmatory factor analyses supported a unidimensional model for the 45 basic lower-extremity and mobility items. Simulated CATs of 5, 10, and 15 items demonstrated excellent accuracy (intraclass correlation coefficients [ICCs] >0.91) with the full item bank and had high correlations with PODCI transfers and mobility (ICC = 0.86) and FAQ scores (ICC = 0.77). All CATs discriminated among GMFCS levels and CP type. The lower-extremity and mobility skills item bank and simulated CATs demonstrated excellent performance over a wide span of ages and severity levels.

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.