Gait Improves After Multilevel Surgery for Children With Cerebral Palsy

By Will Boggs MD

March 28, 2019

NEW YORK (Reuters Health) - Gait improves after multilevel surgery (MLS) for children with cerebral palsy (CP), but long-term gross motor function does not, according to a meta-analysis.

"We think it is interesting to find that so few studies examined how gross motor function, participation, and quality of life change following surgery, as these may be important outcomes for young people with cerebral palsy, and at the moment there is very little evidence that MLS improves them," Dr. Jennifer M. Ryan from Royal College of Surgeons in Ireland, in Dublin, and Brunei University London told Reuters Health by email.

MLS followed by intensive rehabilitation is standard care for reducing musculoskeletal disorders among children with spastic CP, but it remains unclear how effective this approach actually is.

Dr. Ryan and colleagues extracted data from 74 studies, including 3,551 participants, to evaluate gross motor function, gait speed, range of motion, strength, spasticity, participation, quality of life, satisfaction and adverse events following MLS.

The studies included one randomized controlled trial, 52 retrospective cohort studies, 17 prospective cohort studies, and four randomized controlled trials that were treated as cohort studies in pooled analyses because they did not include comparisons of MLS with a control condition.

In pooled analysis, gait improved in children who received MLS compared with those who received resistance training at one year (standardized mean difference, -0.78; P<0.001) and through long-term follow-up, the researchers report in Pediatrics, online March 27.

In one study, walking speed declined immediately after surgery but did not differ significantly in the intermediate- or long-term.

Gross motor function did not improve in the short-, intermediate-, or long-term after MLS, according to pooled analyses.

Passive range of motion at the knee declined immediately after surgery but showed improvements in extension and dorsiflexion in the intermediate- and long-term after MLS.

Pooled analyses showed no evidence for change in muscle strength in the intermediate- or long-term after MLS, but there were significant reductions in spasticity in the short- and intermediate-term.

Participation and quality of life showed improvements after MLS, although only five studies reported these outcomes, and most parents reported satisfaction with surgical outcomes.

The authors could not make conclusions regarding the safety of MLS, as only 17 studies adequately reported adverse events.

"Although we found that MLS results in a small improvement in walking, the studies had a number of potential biases, which make the findings unreliable," Dr. Ryan said. "The majority of studies we identified were conducted by retrospectively reviewing clinical records, which may have led to selection bias. In addition, all but one study did not include a control group of children who did not receive surgery and so we cannot be confident that the effects we found on walking are due to surgery."

"While the quality of gait in terms of joint angles and speed was by far the most commonly assessed outcome it does not capture the effects of surgery on a young person's ability to function or participate in everyday life," she said. "If gross motor function, participation, and quality of life are so rarely examined in research studies, it is unlikely that they are being consistently examined in practice."

"Physicians should consider the effects of MLS on these outcomes and, therefore, assess them before and after MLS," Dr. Ryan said. "Resource restraints may act as a barrier to these assessments, but where possible these outcomes should be taken into account in decision making."

She added, "There is a real need for randomized controlled trials (RCTs) for MLS to provide young people, parents, and surgeons with evidence to guide decision-making. While these are difficult to conduct for several reasons, at the very least future studies need to systematically collect data on surgical procedures, rehabilitation, outcomes, and adverse events. This data needs to be shared across centers conducting MLS in order to improve consistency in decision-making and the provision of MLS to young people with cerebral palsy."

Pam Thomason, a physiotherapist and the manager of Hugh Williamson Gait Analysis Laboratory at The Royal Children's Hospital Melbourne, in Australia, recently reviewed functional mobility and self-care outcomes after multilevel orthopedic surgery in children with cerebral palsy. She told Reuters Health by email, "The results are as expected, as the primary reason for MLS is for deformity correction and improvement in gait."

"Comprehensive evaluation, including instrumented gait analysis, is required to identify the impairments affecting gait function and to quantify the impact of these impairments to ensure the appropriate surgical prescription and dose," said Thomason, who was not involved in the new research.

"RCTs, though the gold standard of trials, are difficult to conduct due to ethical concerns, with the need for a control group necessitating a short follow-up time period," she added. "Prospective long-term cohort studies evaluating all the domains of the International Classification of Functioning, Disability and Health (ICF) model may be a more appropriate way forward for the study of MLS in children with CP."


Pediatrics 2019.