J. Herman

A cohort study of tibialis anterior tendon shortening in combination with calf muscle lengthening in spastic equinus in cerebral palsy

The aim of this study was to evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus. Prospectively collected data was analysed in 26 patients with hemiplegic (n=13) and diplegic (n=13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10-35 years; mean 16.8 years). All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (±5.6months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact, whilst 68% reported improved fitting or reduced requirement of orthotic support. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.15°, p=0.032), maximum ankle dorsiflexion during swing phase (11.68°, p<0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p=0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p=0.024). The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP.

Using a goal attainment scale in the evaluation of outcomes in patients with diplegic cerebral palsy

A goal attainment scale (GAS) was used to evaluate outcomes of surgical and non-surgical interventions to improve gait in 45 children with diplegic cerebral palsy. Personal goals were recorded during pre-intervention gait analysis in two groups. Twenty children underwent orthopaedic surgery (Group 1) and 25 children received a non-operative intervention (Group 2). Children and/or their carers were contacted post-intervention by telephone to complete a GAS questionnaire, rating the achievement of goals on a 5-point scale. The goals were similar in both groups. The composite GAS was transformed into a standardised measure (T-score) for each patient. Both groups on average achieved their goals (mean T-score for Group 2 was 56.3, versus 47.1 for Group 1). The difference between these two means was significant (p=0.010). Additionally, 16 children had undergone a follow-up gait analysis during the study period, but the relationship between their Gait Profile Score and GAS was not statistically significant. Both surgical and non-surgical interventions enabled children to achieve their goals, although Group 1 reported higher achievements. The GAS reflects patients/parents/carers aspirations and may be as relevant as post-intervention kinematic or kinetic outcomes.

The Edinburgh visual gait score – The minimal clinically important difference

OBJECTIVEnThe primary aim was to define the minimal clinically important difference (MCID) of the Edinburgh Visual Gait Score (EVGS) using correlations with the Gross Motor Function Classification System (GMFCS) and the Functional Assessment Questionnaire (FAQ). The secondary aim was to confirm the numerical value of the MCID in the Gait Profile Score (GPS).nnnMETHODnThe EVGS and GPS scores for 151 patients with diplegic cerebral palsy (GMFCS Levels I-III) were retrospectively identified from a database held at the study centre. One-hundred and forty-one patients had FAQ data available.nnnRESULTSnThe EVGS and GPS correlated with increasing GMFCS level (p<0.001) and FAQ score (p<0.001). A gradient of 3.8 (2.9-4.7) for the EVGS and 2.9 (2.1-3.7) for the GPS corresponded to a one-level change in GMFCS level. A gradient of 1.9 (1.3-2.4) for EVGS and 1.5 (1.1-2.0) for GPS corresponded to a one-point change in FAQ.nnnCONCLUSIONSnThe authors propose an MCID value of 2.4 for the EVGS; representing the improvement in gait score after surgery that is likely to reflect a clinical improvement in function. This MCID is closely related to other studies defining post-operative improvements in kinematic data (GPS) and may offer guidance to post-surgical changes that might reasonably be expected to either improve or prevent deteriorating function.