Gait Profile Score Research Articles

Measuring femoral neck anteversion—Validation of a technique based on 3D freehand ultrasound

s / Gait & Posture 39S (2014) S1–S141 S53 Fig. 1. Change in GPS after 2y ML surgery vs baseline GPS. (age 6–24yrs), who could walk independently or with aids, had undergone SEMLS at our hospital, and had a pre-op as well as post-op gait analysis at around two years following surgery (conventional gait model). The Gait Profile Score (GPS) [2] was selected as a primary outcomemeasure. Predictor variables included (1) age at surgery, (2) pre-opGPS, (3) unilateral or bilateral surgery, and (4) soft tissueonlyorother surgery. Regressionanalysiswasperformed with significance set at p<0.05. Predictor variables were compared to both the post op GPS, as well as the change in GPS compared to pre-op. Results: Overall, 75% of patients demonstrated improvement that exceeded theMCID of 1.6◦, while only 2% deteriorated according to the same criteria. The average improvement in GPS was 3.2◦. Pre-op GPS was found to be the strongest predictor of change (b=0.57, p<0.001) (Fig. 1). It was also found to be a significantly associated with absolute GPS post-op (p<0.001). Age at surgery was found to be a significant predictor of change (p=0.02), but not absolute GPS following surgery (p=0.61). Bilateral compared to unilateral surgery was associated with a greater change (p=0.001) but post-op GPS was not significantly correlated (p=0.01). While the soft tissue surgery subjects, when compared to other surgeries,wasnot a significant predictor of change (p=0.60) or outcome (p=0.37). Discussion and conclusions: This study builds on previous work conducted elsewhere [3] which assessed outcomes one year following SEMLS, and confirms that pre-op GPS is the strongest predictor of improvement. The work presented here shows that this is maintained up to two years following surgery. In addition, pre-op GPS was demonstrated here to be a good predictor of absolute GPS post op. Significant correlation of change, but not final GPS, with bilateral/unilateral surgery would suggest this is related to severity of involvement. Interestingly, the same trend was not observed where soft tissue only surgery was performed, however this may be related to the relatively small sample size (around 10% of patients). Encouragingly, the vast majority of subjects improved following SEMLS by an average of 3.2◦, and this trend was maintained over a significant period of time. Based on the findings of this study the expected change in GPS following SEMLS can be approximated by the following equation: GPS Improvement = (0.6×pre-op GPS)− (0.1× age)−2.6. Reference [1] Thomason, et al. JBJS(A) 2014;93:451–60 [in press]. [2] Baker, et al. Gait Posture 2014;30:265–9 [in press]. [3] Rutz, et al. Gait Posture 2014;36:S6 [in press]. http://dx.doi.org/10.1016/j.gaitpost.2014.04.073

Altered trunk movements during gait in children with spastic diplegia: compensatory or underlying trunk control deficit?

Altered trunk movements during gait in children with CP are considered compensatory due to lower limb impairments, although scientific evidence for this assumption has not yet been provided. This study aimed to study the functional relation between trunk and lower limb movement deficits during gait in children with spastic diplegia. Therefore, the relationship between trunk control in sitting, and trunk and lower limb movements during gait was explored in 20 children with spastic diplegia (age 9.2 ± 3 yrs; GMFCS level I n=10, level II n=10). Trunk control in sitting was assessed with the Trunk Control Measurement Scale (TCMS), a clinical measure that reflects the presence of an underlying trunk control deficit. Trunk movements during gait were measured with a recently developed trunk model including the pelvis, thorax, head, shoulder line and spine. Lower limb movements were assessed with the Plug-in-Gait model (Vicon(®)). Range of motion (ROM) of the different trunk segments was calculated, as well as the Trunk Profile Score (TPS) and Trunk Variable Scores (TVSs). Similarly, the Gait Profile Score (GPS) and Gait Variable Scores (GVSs) were calculated to describe altered lower limb movements during gait. Correlation analyses were performed between the presence of impaired trunk control in sitting (TCMS) and altered trunk movements during gait (ROM, TPS/TVSs) and between these altered trunk movements and lower limb movements (GPS/GVSs) during gait. A poorer performance on the TCMS correlated with increased ROM and TPS/TVSs, particularly for the thorax, indicating the presence of an underlying trunk control deficit. No significant correlation was found between the TPS and GPS, suggesting that overall trunk and lower limb movement deficits were not strongly associated. Only few correlations between specific lower limb deficits (GVSs for hip ab/adduction, knee flexion/extension and ankle flexion/extension) and TVSs for thorax lateral bending and rotation were found. This study provided first evidence that the altered trunk movements observed during gait should not be solely considered compensatory due to lower limb impairments, but that these may also partially reflect an underlying trunk control deficit. A better understanding of underlying trunk control deficits in children with CP may facilitate targeted therapy planning and ultimately can optimize a child's functionality.

Slipped capital femoral epiphysis, fixation by single screw in situ: A kinematic and radiographic study

BackgroundSlipped capital femoral epiphysis is known to produce characteristic deformities in the proximal femur, which affect hip motion and may cause a limp. This paper assessed the 3D gait kinematics in adolescents after single screw fixation of moderate to severe, stable, unilateral slipped capital femoral epiphysis. Our goals were to characterize the 3D kinematic patterns and to investigate the correlation between the severity of radiological deformity and severity of gait disturbance. MethodsThis was a retrospective study of patients seen at our institution between 2000 and 2009. Antero–posterior and frog lateral X-rays were reviewed to measure: Southwick's lateral slip angle, the alpha angle of Notzli and Klein's line offset. Quantitative 3D gait data was collected using a state of the art motion capture system. Kinematic waveforms were compared using a functional data analysis version of the t-test. FindingsThere were 30 patients with an average age at pinning of 13y (10–17y). Mean gait profile scores were significantly abnormal for slipped side (10.8°) versus sound side (6.8°), slipped side versus normal (5.6°) and sound side versus normal. There was little statistically significant correlation between severity of radiographic deformity and degree of gait disturbance. InterpretationMajor kinematic pattern deviations could be associated with (a) morphology of the proximal femur and potential femoral acetabular impingement problems and (b) leg length discrepancy. Gait analysis was able to quantify the kinematic deviations due to the anatomical deformities.

Effects of gastrocnemius fascia lengthening on gait pattern in children with cerebral palsy using the Gait Profile Score

The aim of the present study was to investigate the efficacy of the GPS regarding the quantification of changes in gait following the gastrocnemius fascia lengthening in children with CP. Nineteen children with CP were selected and evaluated in the preoperative period (PRE session) and approximately one year postoperatively (POST session; mean 13.1 ± 5.1 months) using 3D gait analysis and computing the GPS and GVSs. As the GPS represents the difference between the patient's data and the average from the reference dataset, the higher the value of GPS is, more compromised gait of the subject. A statistically significant improvement in mean GPS was found in the POST session (PRE: 13.38 ± 5°; POST: 10.26 ± 2.41°; p<0.05), with an improvement close to 23%. Moreover, the GVSs demonstrated statistically significant improvements in ankle dorsi-plantarflexion (PRE: 22.20 ± 16.36°; POST: 11.50 ± 6.57°; p<0.05) and pelvic rotation (PRE: 9.53 ± 3.87°; POST: 6.47 ± 2.98°; p<0.05). A strong correlation (r=0.75; p<0.05) was found between the preoperative GPS and the percentage of GPS improvement. The results demonstrated that the gastrocnemius fascia lengthening produced a global gait pattern improvement, as showed by the GPS value, which decreased after surgery. Besides this, the GVS permitted to better evidence the joints more compromised by the pathology and their improvement due to the surgery, in this case not only the GVS of the ankle joint but also of the pelvis were characterized by higher GVS values.

Movement deviation and asymmetry assessment with three dimensional gait analysis of both upper- and lower extremity results in four different clinical relevant subgroups in unilateral cerebral palsy

BackgroundIn unilateral cerebral palsy, movement pattern can be difficult to define and quantify. The aim was to assess the degree of deviation and asymmetry in upper and lower extremities during walking. MethodsForty-seven patients, 45 Gross Motor Function Classification Scale (GMFCS) I and 2 patients GMFCS II, mean age 17.1 years (range 13.1 to 24.0) and 15 matched controls were evaluated. Gait profile score (GPS) and arm posture score (APS) were calculated from three-dimensional gait analysis (GA). Asymmetry was the calculated difference in deviation between affected and unaffected sides. FindingsThe GPS was significantly increased compared to the control group on the affected side (6.93 (2.08) versus 4.23 (1.11) degrees) and on the unaffected side (6.67 (2.14)). The APS was also significantly increased on the affected side (10.39 (5.01) versus 5.52 (1.71) degrees) and on the unaffected side (7.13 (2.23)). The lower extremity asymmetry increased (significantly) in comparison with the control group (7.89 (3.82) versus 3.90 (1.01)) and correspondingly in the upper extremity (9.75 (4.62) versus 5.72 (1.84)). The GPS was not different between affected and unaffected sides, however the APS was different (statistically significant). InterpretationWe calculated deviation and asymmetry of movement during walking in unilateral CP, identifying four important clinical groups: close to normal, deviations mainly in the leg, deviations mainly in the arm and those with deviation in the arm and leg. This method can be applied to any patient group, and aid in diagnosing, planning treatment, and prognosis.

Progressive resistance exercise increases strength but does not improve objective measures of mobility in young people with cerebral palsy.

Question Does progressive resistance training (PRT) improve mobility and muscle strength in young people with cerebral palsy (CP)? Design Randomised, controlled trial with concealed allocation and blinded outcome assessment. Setting Recruitment from a large metropolitan children's hospital and a CP register in Australia. Participants Participants had spastic diplegia CP, were aged 14 years to 22 years, had a disability classified as level II or III on the Gross Motor Function Classification System. Exclusion criteria were participation in PRT in the previous six months, single-event multi-level surgery in the previous two years, or contractures more than 20° at the hips and knees. Randomisation of 49 participants allocated 24 to the PRT group and 25 to the control group. Interventions The intervention group participated in a twice-weekly, 12-week PRT program performed at community gymnasia. Training was completed alone or in pairs under the supervision of a physiotherapist. Each participant was prescribed four to six individualised exercises, which were targeted to address deficits that had been identified by instrumented gait analysis, supplemented by clinical assessment. Participants completed three sets of 10 to 12 repetitions of each exercise at an intensity of 60% to 80% of one repetition maximum (RM). The control group continued with their usual recreation and physiotherapy provided it did not include PRT. Outcome measures The primary outcome was the six-minute walk test at week 13 and at week 24. Secondary outcome measures assessed objective mobility-related function (self-selected walking speed, timed stairs test, Gross Motor Function Measure (GMFM-66) dimensions D and E, Gait Profile Score), participant-rated mobility (Functional Mobility Scale, Functional Assessment Questionnaire) and muscle performance (1-RM) of leg press and reverse leg press). Results Forty-eight participants completed the study. After 12 weeks of training, there was no difference between the groups for the six-minute walk (0.1 m, 95% CI -20.6 to 20.9), stairs test (-0.9 s, 95% CI -4.7 to 2.9), GMFM dimension D (-1.3%, 95% CI -4.8 to 2.4) and E (0.9%, 95% CI -3.0 to 4.7), and reverse leg press 1-RM (-0.7 kg, 95% CI -4.3 to 2.8). The intervention group showed significant improvement in the Functional Mobility Scale at 5 m (0.6 units, 95% CI 0.1 to 1.1), the Functional Assessment Questionnaire (0.8 units, 95% CI 0.1 to 1.6) and leg press 1-RM (14.8 kg, 95% CI 4.3 to 25.3), compared with the control group. At week 24, there were no differences between the groups for any outcome. The groups did not significantly differ for the remaining secondary outcomes at either time-point. Conclusion Individualised PRT increases strength in young people with CP. The participants thought their mobility had improved, although objectively it had not.

Validation of GDI, GPS and GVS for use in Parkinson's disease through evaluation of effects of subthalamic deep brain stimulation and levodopa

The Gait Deviation Index (GDI), Gait Profile Score (GPS) and Gait Variable Scores (GVSs) have been proposed as measures of gait quality and validated for use with children with cerebral palsy. The aim of this study was to extend this validation to people with Parkinson's disease by evaluating the effects of subthalamic deep brain stimulation and levodopa on gait. 16 participants had their gait evaluated with stimulation, medication or a combination of both. The Unified Parkinson's Disease Rating Scale (UPDRS) showed statistically significant differences in agreement with previous studies. The GPS and GDI showed similar treatment effects as did GVS for hip and knee flexion/extension, as assessed with Cohen's d where medium or large. Overall the results suggest that these gait indices are sensitive to treatment in this group of patients and that their use in groups other than children with cerebral palsy is valid.

Gait profile score and movement analysis profile in patients with Parkinson's disease during concurrent cognitive load.

Background: Gait disorders are common in individuals with Parkinson's Disease (PD) and the concurrent performance of motor and cognitive tasks can have marked effects on gait. The Gait Profile Score (GPS) and the Movement Analysis Profile (MAP) were developed in order to summarize the data of kinematics and facilitate understanding of the results of gait analysis. Objective: To investigate the effectiveness of the GPS and MAP in the quantification of changes in gait during a concurrent cognitive load while walking in adults with and without PD. Method: Fourteen patients with idiopathic PD and nine healthy subjects participated in the study. All subjects performed single and dual walking tasks. The GPS/MAP was computed from three-dimensional gait analysis data. Results: Differences were found between tasks for GPS (P<0.05) and Gait Variable Score (GVS) (pelvic rotation, knee flexion-extension and ankle dorsiflexion-plantarflexion) (P<0.05) in the PD group. An interaction between task and group was observed for GPS (P<0.01) for the right side (Cohen's ¯d=0.99), left side (Cohen's ¯d=0.91), and overall (Cohen's ¯d=0.88). No interaction was observed only for hip internal-external rotation and foot internal-external progression GVS variables in the PD group. Conclusions: The results showed gait impairment during the dual task and suggest that GPS/MAP may be used to evaluate the effects of concurrent cognitive load while walking in patients with PD.

The efficacy of neuroprosthesis in young hemiplegic patients, measured by three different gait indices: Early results

To evaluate functional electrical stimulation (FES) neuroprothesis as a method to improve gait in hemiplegic patients, using three different gait scoring methods as measures. Five hemiplegic patients (four with cerebral palsy at GMFCS I, one with diffuse pontine glioma) with a mean age of 16.5years were given a FES neuroprosthesis (NESS(®) L300™) that was applied and calibrated individually. After an adaptation period during which the participants increased their daily use of the neuroprosthesis, gait was assessed with the stimulation off and with the FES on. Kinematic, kinetic, and temporal spatial data were determined using motion analysis and summarized by three scoring methods: Gait Profile Score (GPS), Gait Deviation Index (GDI), and Gillette Gait Index (GGI). Indices were calculated using the Gaitabase program available online. Patients were followed for a minimum of 1year. When comparing gait with and without stimulation, all scoring methods showed improvement. GPS and GDI of the affected leg were significantly improved: 12.23-10.23° (p=0.017) and 72.36-78.08 (p=0.002), respectively. By applying the movement analysis profile, the decomposed GPS score, we found that only the ankle dorsiflexion and the foot progression angle were significantly changed. GGI of the affected leg showed improvement, but without statistical significance: 168.88-131.64 (p=0.221). Total GPS of legs and the GPS, GDI, and GGI of the nonaffected leg showed improvement without statistical significance. At the 1-year follow-up, all patients expressed high satisfaction and continued to use the device. Dorsiflexion functional electrical stimulation improves gait in hemiplegic patients, as reflected by GPS, GDI, and GGI.

The influence of walking speed on the Gait Deviation Index in individuals with Rheumatoid Arthritis

groups: Orthopaedic uni-/bilateral (OUni/OBi); neurological flaccid uni-bilateral (NflaUni/NflaBi); neurological spastic uni-/bilateral with/without adequate trunk control (NspUni/NspBi/NspBiNTC). The gait profile score (GPS) [1] was calculated. The mean MMS, derived by clinical testing [2], was the mean over all leg muscle groups. General least square models (software R 2.12.0) were used to assess whether the effects of MMS on GPS differ among patient groups. The GPS offsets at a MMS of 5 were compared between OUni and the other patient groups (Fig. 1). Results:MMS had a strong, negative effect on GPS score (MMS: −3.0±0.2, p< .001). There were no significant differences in this effect among patient groups (p= .848). However, they strongly differed in GPS offset at a MMS of 5 (p< .001) (Table 1). Discussion and conclusions: The amount of gait deviation increased with the loss of muscle strength, and this behaviour seemed to be independent of the pathology. The severity of the pathologywas reflected in the higher GPS (i.e. kinematic deviation) at normal MMS. Note that NflaUni is an exception, possibly biased by the small patient number (n=12). We conclude that gait deviationsmainly result frommuscleweakness. This knowledge canfind clinical implication in treatment planning and in the interpretation of gait compensations in patientswith various constraints. The role of the basic disease should not be overemphasised.

Gait kinematics and radiographic deformity following slipped upper femoral epiphysis

Introduction: Slipped upper femoral epiphysis (SUFE) results in hip deformity and femoro-acetabular impingement (FAI). FAI affects hip motion and impacts on gait. The purpose of this study was to quantify the effects of moderate to severe SUFE on 3D gait kinematics and to determine if there were correlations between gait deviations and slip severity. Patients/materials andmethods: Patients referred to the Royal Children’s Hospital for a 3D gait analysis (3DGA) between 2000 and 2009 after pinning in situ of a stable SUFE were studied retrospectively. Inclusion criteria were unilateral SUFE, Southwick Lateral Slip Angle (LSA)≥30◦, [1], no surgical complications, appropriate hip and pelvis radiology and 3DGA. 3DGA was performed with a Vicon motion system (OMG, UK) and followed the Plug in Gait (VICON, UK) protocol. Gait variable score (GVS) and Gait profile score (GPS) [2], were calculated on the study cohort for both the sound and slipped side, compared to 38 paediatric subjects with no gait pathology (NGP), using t-test with unequal variances ( =0.05) in Minitab (Minitab, Inc., USA). Results:30Patients (17Male, 13 Female),with an average age at pinning of 13.3 years (±1.9 years) were included. The average LSA, Klein’s line offset and alpha angle of Noztli were 45.3◦ (±13.0◦), −6.4mm (±8.0mm) and 113.6◦(±13.1◦) respectively. The GPS and all GVS, except pelvic tilt (sound and slip side) and foot progression (sound side), were significantly different compared to the NGP group. Hip rotation and foot progression GVSs as well as GPS were significantly different between the slipped and sound sides. However, no significant correlations were found between GVSs and the radiological measurements.

Correlation of radiological outcome and gait function of SCFE patients after growth arrest

Introduction: Slipped upper femoral epiphysis (SUFE) results in hip deformity and femoro-acetabular impingement (FAI). FAI affects hip motion and impacts on gait. The purpose of this study was to quantify the effects of moderate to severe SUFE on 3D gait kinematics and to determine if there were correlations between gait deviations and slip severity. Patients/materials andmethods: Patients referred to the Royal Children’s Hospital for a 3D gait analysis (3DGA) between 2000 and 2009 after pinning in situ of a stable SUFE were studied retrospectively. Inclusion criteria were unilateral SUFE, Southwick Lateral Slip Angle (LSA)≥30◦, [1], no surgical complications, appropriate hip and pelvis radiology and 3DGA. 3DGA was performed with a Vicon motion system (OMG, UK) and followed the Plug in Gait (VICON, UK) protocol. Gait variable score (GVS) and Gait profile score (GPS) [2], were calculated on the study cohort for both the sound and slipped side, compared to 38 paediatric subjects with no gait pathology (NGP), using t-test with unequal variances ( =0.05) in Minitab (Minitab, Inc., USA). Results:30Patients (17Male, 13 Female),with an average age at pinning of 13.3 years (±1.9 years) were included. The average LSA, Klein’s line offset and alpha angle of Noztli were 45.3◦ (±13.0◦), −6.4mm (±8.0mm) and 113.6◦(±13.1◦) respectively. The GPS and all GVS, except pelvic tilt (sound and slip side) and foot progression (sound side), were significantly different compared to the NGP group. Hip rotation and foot progression GVSs as well as GPS were significantly different between the slipped and sound sides. However, no significant correlations were found between GVSs and the radiological measurements.

Use of the gait profile score and movement analysis profile in patients with parkinson's disease during dual task

Use of the gait profile score and movement analysis profile in patients with parkinson's disease during dual task

Use of the Gait Profile Score for the evaluation of patients with joint hypermobility syndrome/Ehlers–Danlos syndrome hypermobility type

Gait analysis (GA) is widely used for clinical evaluations in various pathological states, both in children and in adults, such as in patients with joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type (JHS/EDS-HT). Otherwise, GA produces a large volume of data and there is the clinical need to provide also a quantitative measure of the patient's overall gait. Starting from this aim some global indexes were proposed by literature as a summary measure of the patient's gait, such as the Gait Profile Score (GPS). While validity of the GPS was demonstrated for the evaluation of the functional limitation of children with Cerebral Palsy, no studies have been conducted in patients JHS/EDS-HT. The aim of our study was therefore to investigate the effectiveness of the GPS in the quantification of functional limitation of patients with JHS/EDS-HT. Twenty-one adult (age: 36.1 ± 12.7 years) individuals with JHS/EDS-HT were evaluated using GA and from GA data the GPS was computed. The results evidenced that the GPS value of patients was 8.9 ± 2.6, statistically different from 4.6 ± 0.9 displayed by the control group. In particular, all values of Gait Variable Scores (GVS) which compose the GPS were higher if compared to controls, with the exception of Pelvic Tilt and Foot Progression. The correlations between GPS/GVS and Lower Extremity Functional Scale (LEFS) showed significant relationship between GPS and the item 11 ("Walking 2 blocks") (ρ=-0.56; p<0.05) and 12 ("Walking a mile") of LEFS (ρ=-0.76; p<0.05). Our results showed that GPS and GVS seem to be appropriate outcome measures for the evaluation of the functional limitation during gait of patients with JHS/EDS-HT.

Self-Selected Walking Speed Predicts Ability to Run Following Traumatic Brain Injury

To identify factors that predict running ability following traumatic brain injury (TBI), and to quantify performance thresholds for these predictors. Cross-sectional cohort study. One hundred fourteen people with TBI. Self-selected walking speed, the high-level mobility assessment tool, postural stability (lateral center of mass displacement), ankle power generation at push-off and quality of gait performance (Gait Profile Score). All predictor variables were all strongly associated with the ability to run. However, only self-selected walking speed contributed significantly to the final result. Investigation of performance thresholds for self-selected walking speed indicated that following TBI, people who walk at speeds of 1.0 m/s or higher are 16.9 times more likely of being able to run than for those who walk at speeds of less than 1.0 m/s. Self-selected walking speeds higher than 1.0 m/s greatly increase the likelihood of running following brain injury. The 1.0 m/s threshold, although slower than able-bodied self-selected walking speeds, may be an important indicator of the ability to run in this population.

One side or two?

One side or two?

The influence of muscle strength on the gait profile score (GPS) across different patients

BackgroundMuscle strength greatly influences gait kinematics. The question was whether this association is similar in different diseases. MethodsData from instrumented gait analysis of 716 patients were retrospectively assessed. The effect of muscle strength on gait deviations, namely the gait profile score (GPS) was evaluated by means of generalised least square models. This was executed for seven different patient groups. The groups were formed according to the type of disease: orthopaedic/neurologic, uni-/bilateral affection, and flaccid/spastic muscles. ResultsMuscle strength had a negative effect on GPS values, which did not significantly differ amongst the different patient groups. However, an offset of the GPS regression line was found, which was mostly dependent on the basic disease. Surprisingly, spastic patients, who have reduced strength and additionally spasticity in clinical examination, and flaccid neurologic patients showed the same offset. Patients with additional lack of trunk control (Tetraplegia) showed the largest offset. ConclusionGait kinematics grossly depend on muscle strength. This was seen in patients with very different pathologies. Nevertheless, optimal correction of biomechanics and muscle strength may still not lead to a normal gait, especially in that of neurologic patients. The basic disease itself has an additional effect on gait deviations expressed as a GPS-offset of the linear regression line.

Do Movement Deviations Influence Self-Esteem and Sense of Coherence in Mild Unilateral Cerebral Palsy?

Individuals with unilateral cerebral palsy (CP) are often physically high functioning. Despite the mildness of the impairment, the movement deviations during walking are often noticeably deviant. In the arm, increased muscle tone causes posturing and decreased motion. In the lower extremity, gait deviations mainly involve the foot and ankle. The deviations often become more apparent with transitions between movements and during rapid movement but also when the person is emotionally affected. Arm posturing and gait deviations may be perceived as cosmetic and social impediments when the individual enters adolescence and becomes more self-conscious. The aim was to study the influence of movement deviations in the upper and lower extremity during walking, on self-esteem, and sense of coherence (SOC) in teenagers and young adults with mild unilateral CP. Three-dimensional gait analysis was performed with an 8-camera system. Movement deviations of the lower extremity, the Gait Profile Score (GPS) and of the upper extremity, and the Arm Posturing Score (APS) were calculated. Self-reported questionnaires "I think I am" measuring self-esteem and SOC were used. Forty-four patients with a mean age of 17.6 years (range, 13.0 to 24.0 y), 22 females and 22 males, and 15 sex-matched and age-matched controls participated in the study. Forty-two patients were classified as Gross motor function classification scale (GMFCS) I and 2 as GMFCS II. Patients were rated with lower self-esteem than controls (mean, 63.4 vs. 84.7; P=0.025). The SOC assessments revealed no difference. The GPS and APS was higher in patients (6.9 vs. 4.1; P<0.001) and (mean, 10.5 vs. 5.7; P<0.001), respectively. The APS correlated with both self-esteem (coefficient -0.397; P=0.001) and SOC (coefficient -0.375; P=0.05). No correlations were found with the GPS. Although physically high functioning, movement deviations in teenagers and young adults with mild unilateral CP are correlated with lower self-esteem. This is more pronounced with increased arm movement deviation and should be considered when evaluating these individuals. Prospective cross-sectional study. Level III.

Explaining the variability improvements in gait quality as a result of single event multi-level surgery in cerebral palsy

PurposeThis is a study of all children with spastic diplegic cerebral palsy (Gross Motor Classification System levels II and III) who had single event multi-level surgery (SEMLS) at a single tertiary referral hospital between 1995 and 2008 to identify factors predicting improvement in gait quality as quantified by the gait profile score (GPS). 9 factors (5 dichotomous and 4 continuous, including preoperative GPS) that might be expected to predict outcomes were identified and univariate and multivariable analysis used to explore how these affected outcomes. ScopeData from 121 children were included. The mean improvement in GPS of 4.3° was 2.7 times the minimal clinically important difference. Univariate analysis suggested that preoperative GPS is a very strong predictor of improvement in GPS (p<10−5) and when this is considered as a covariate only GMFCS level (p=10−5) and having had previous surgery (p=0.026) were found to be statistically significant predictors of GPS improvement (p<0.05). Children of GMFCS level II improved on average by 2° more than those of level III once differences in preoperative GPS had been accounted for. ConclusionChildren with the most abnormal gait patterns preoperatively, and hence those with the most potential to improve are those that improve the most and surgery has clearly been beneficial. Over a quarter of children show changes in GPS which were less than the MCID. The majority of these were those with the least abnormal gait patterns preoperatively and further research is required to establish whether and how such children benefit from SEMLS.

Are Results After Single-event Multilevel Surgery in Cerebral Palsy Durable?

Gait and function may deteriorate with time in patients with spastic diplegia. Single-event multilevel surgery often is performed to either improve gait or prevent deterioration. However it is unclear whether the presumed gait improvements are durable. We therefore determined whether (1) single-event multilevel surgery improves gait in patients with spastic diplegia and (2) whether the improved function is durable. We retrospectively reviewed the data of 14 patients with spastic diplegia. At the time of surgery, one patient had gross motor Level I function, 10 patients had Level II function, and three patients had Level III function. There were four females and 10 males with a mean age of 13 years (range, 7-18 years). The mean number of orthopaedic procedures per single-event multilevel surgery session was 7.4 ± 2.8 (median, 6.5; range, 4-15). We used instrumented gait analysis to determine joint ROM, movement analysis profiles, and the gait profile score. The minimum followup was 1 year (mean, 2 years; range, 1-3 years). At last followup, movement analysis profiles for knee flexion, for ankle dorsiflexion, and for foot progression improved as did the gait profile score. Additional surgery after the index procedure was performed in nine of the 14 patients because of relapse of the original or new gait problems. Major surgical adverse events occurred in one of the 14 patients. Severe gait dysfunction in patients with spastic diplegia can be improved short-term in one operative session by single-event multilevel surgery, but to preserve the early improvements many patients require additional surgery. It is unknown whether the improvements will last for decades. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.