Ganganalyse til børn med CP - cpop.dk · Ganganalyse til børn med CP – Delresultater fra kliniske forskningsprojekter Helle Mätzke Rasmussen Department of Clinical Research Faculty

Ganganalyse til børn med CP

– Delresultater fra kliniske forskningsprojekter

Helle Mätzke RasmussenDepartment of Clinical Research

Faculty of Health Sciences University of Southern Denmark

Orthopaedic Research Unit Department of Orthopaedic Surgery and Traumatology

Odense University Hospital

CPOP DAG 2016

2

Afhandling og artikler

The use of instrumented gait analysis

in interdisciplinary interventions for

children with cerebral palsy

Print Print & Sign, Syddansk Universitet

Frontpage Frida Danielsson (model) - Heidi Lundsgaard (photo)

PhD Thesis (2018) The use of instrum

ented gait analysis in interdisciplinary interventions for children with cerebral palsy

Helle Mätzke Rasmussen

Department of Clinical Research Orthopaedic Research Unit

Faculty of Health Sciences Department of Orthopaedic Surgery and Traumatology

University of Southern Denmark Odense University Hospital

I Rasmussen HM, Nielsen DB, Pedersen NW, Overgaard S, Holsgaard-Larsen A. Gait Deviation Index, Gait Profile Score and Gait Variable Score in children with spastic cerebral pal-sy: Intra-rater reliability and agreement across two repeated sessions. Gait & Posture. 2015;42(2):133-7.

IIa Rasmussen HM, Pedersen NW, Overgaard S, Hansen LK, Dunkhase-Heinl U, Petkov Y, Engell V, Baker R, and Hols-gaard-Larsen A. The use of instrumented gait analysis for in-dividually tailored interdisciplinary interventions in children with cerebral palsy: a randomised controlled trial protocol. BMC Pediatrics. 2015;15(1):202.

IIb Rasmussen HM, Pedersen NW, Overgaard S, Hansen LK, Dunkhase-Heinl U, Petkov Y, Engell V and Holsgaard-Larsen A. The use of instrumented gait analysis for individually tail-ored interdisciplinary interventions in children with cerebral palsy: a randomised controlled trial. [Re-submitted to Dev Med Child Neurol, Feb 2018].

III Rasmussen HM, Svensson J, Christensen MT, Pedersen NW, Overgaard S, Holsgaard-Larsen A. Threshold values of ank-le dorsiflexion and gross motor function in 60 children with cerebral palsy – a cross-sectional study [Acta Orthop, 2018 Mar 28:1-6 Epub ahead of print].

3

Population

GMFCS E & R mellem 6 og 12 år: Beskrivelser og illustrationer

GMFCS niveau V Børnene transporteres i en manuel kørestol i alle omgivelser. Børnene er begrænsede i evnen til at holde hovedet og kroppens stillinger oppe imod tyngden og de er begrænsede i styringen af bevægelserne i ben og arme.

GMFCS niveau IVBørnene bevæger sig omkring i de fleste omgivelser ved hjælp af fysisk støtte eller ved brug af el-kørestol. De kan måske gå omkring på korte distancer i hjemmet når de får fysisk støtte, når de er placeret i kropsstøttende gangredskab eller de bruger el-kørestol. I skolen, udenfor og i nærmiljøet transporteres børnene i en manuel kørestol eller de anvender en el-kørestol.

GMFCS niveau IIIBørnene går ved brug af håndholdt gangredskab i de fleste indendørs omgivelser. De kan måske gå på trapper, når de holder ved gelænder, med supervision eller støtte. Børnene bruger kørestol på længere distancer og kan måske selv køre manuel kørestol på kortere distancer.

GMFCS niveau IIBørnene kan gå i de fleste omgivelser og kan gå på trapper når de holder ved gelænder. De vil måske have vanskeligheder når de går lange distancer og når de går i ujævnt terræn, på stigninger, og når der er begrænset plads og når der er mange mennesker tæt på. Børnene vil måske gå med fysisk støtte, med et håndholdt gangredskab eller bruge en kørestol på længere distancer. Børnene har begrænsede evner til at udføre grovmotoriske aktiviteter som løb og hop.

GMFCS niveau IBørnene går i hjemmet, i skolen, udendørs og i nærmiljøet. De kan gå på trapper uden støtte ved gelænder. Børnene udfører grovmotoriske aktiviteter som at løbe og hoppe, men tempo, balance og koordination er begrænset.

GMFCS descriptors: Palisano et al. (1997) Dev Med Child Neurol 39:214–23 CanChild: www.canchild.ca

Illustrations Version 2 © Bill Reid, Kate Willoughby, Adrienne Harvey and Kerr Graham, The Royal Children’s Hospital Melbourne ERC151050

Translation to Danish: Kirsten Nordbye-Nielsen, [email protected] Aarhus University Hospital, Denmark. May 2017










I II

Rosenbaum PL at al (2008) www.canchild.ca60% of childen with CP

Rodby-Bousquet & Hägglund (2012)

Children with spastic cerebral palsyGMFCS level I and II

5-8 years of age

4

Rasmussen et al (2016)

The Danish Cerebral Palsy Follow-up Program (CPOP)National clinical quality database & Follow-up program

Standardized examinations Gross motor function

Muscle tone Passive range of motion

Orthotics and assistive devices

www.cpguiden.dk

5

Planning of interventions

Local teams

Interdisciplinary consultations

Examinations Gross motor function

Gait pattern

InterventionsRasmussen (2016)

www.cpguiden.dk

6

Gait analysis

- Movements (kinematic)- Forces (kinetics) Gage (1994)

- Diagnose and monitor progressBaker (2016)

9

Gait analysis

- 40-70% Changes in treatment plansLofterod (2007), Cook (2003), Kay (2000), Deluca (1997) - 77-97% ComplianceWren TA (2013), Lofterod (2007), Wren TA (2005)

- Effectiveness of interventionsFranki (2014), Van den Broeck (2010), Wren (2013)

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Data from gait analysis

Clinical practise

Impairment focused interpretation (Baker 2009)

- History- Orientation: Gait indices- Video- Evidence and interpretation- Kinematic / kinetic graphs- Physical examination- Patient reported outcome measures

Example: Ankle dorsi flexion

d Too little right dorsiflexion in stancee too little dorsiflexion in swing.

Test

Team A

Retest

Laboratory Team B

Team C

+

+

+

Ganganalyse rapport

Kinematic / kinetic graphs

Projekt ID ViTo2008 / ID223

Dato 14-‐10-‐2015

The report is based on a clinical gait analysis, that have been performed as part of a research project, that is conducted at the Gait Analysis Laboratory by physiotherapist Helle Mätzke Rasmussen. HMR / 2014-‐09-‐01 / Based on a template by Baker, McGinley and Thomason (2010) 7

Gait data

Pelvic Tilt Pelvic Obliquity Pelvic Rotation

Hip Flexion Hip Adduction Hip rotation

Knee Flexion

Dorsiflexion

Foot Progression

b

a

c

d

d

e

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Data from gait analysis

Research: Gait indices

Gait Deviation IndexSchwartz (2008)

Gait Profile Score Baker (2009)

Gait Variable Score Movement Analysis Profile

Subjects

Pelvis Ant/PstHip Flx/Ext

Knee Flx/ExtAnkle Dor/PlaPelvic Up/DnHip Add/AbdPelvic Int/Ext

Hip Int/ExtFoot Int/Ext

GPS

Controls

Pelvis Ant/PstHip Flx/Ext

Knee Flx/ExtAnkle Dor/PlaPelvic Up/DnHip Add/AbdPelvic Int/Ext

Hip Int/ExtFoot Int/Ext

GPS

0

5

10

15

20

Med

ianan

dIQRRM

Sdiffe

rencefrom

con

trolm

ean(degrees)

MovementAnalysisProfile

Le( Right Overall

0

5

10

15

20

MovementAnalysisProfile

I suggest you use a screen dump to copy this graphic as it is actully two graphs laid on top of each other to get the overlay effect. Press <alt+prtscr> to copy to clipboard, paste and then crop to rdisplay just the graph.

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Combining the CPOP with the use of gait analysis

Motivation for the studies

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Study aimThis study aimed to determine if indivi-dually tailored interdisciplinary interventions with gait analysis lead to greater improvements than individu-ally tailored interdisciplinary intervention without gait analysis in overall gait pathology, walking perfor-mance and patient-reported outcome measures of function, disability and health-related quality of life.

Protocol article:Rasmussen HM, edersen NW, Overgaard S, Hansen LK, Dunkhase-Heinl U, Petkov Y, Engell V, Baker R, Holsgaard-Larsen, A BMC Pediatrics (2015)

Article IIb - resubmitted

Study aim

STUDY PROTOCOL

Open AccessThe use of instrumented gait analysis forindividually tailored interdisciplinaryinterventions in children with cerebralpalsy: a randomised controlled trialprotocolHelle Mätzke Rasmussen1,2*, Niels Wisbech Pedersen1,2, Søren Overgaard1,2, Lars Kjaersgaard Hansen3,

Ulrike Dunkhase-Heinl4,5, Yanko Petkov6, Vilhelm Engell1,2, Richard Baker7 and Anders Holsgaard-Larsen1,2Abstract

Background: Children with cerebral palsy (CP) often have an altered gait. Orthopaedic surgery, spasticity management,

physical therapy and orthotics are used to improve the gait. Interventions are individually tailored and are

planned on the basis of clinical examinations and standardised measurements to assess walking (‘care as usual’).

However, these measurements do not describe features in the gait that reflect underlying neuro-musculoskeletal

impairments. This can be done with 3-dimensional instrumented gait analysis (IGA). The aim of this study is to test the

hypothesis that improvements in gait following individually tailored interventions when IGA is used are superior to

those following ‘care as usual’.Methods/Design: A prospective, single blind, randomised, parallel group study will be conducted. Children aged 5

to 8 years with spastic CP, classified at Gross Motor Function Classification System levels I or II, will be included. The

interventions under investigation are: 1) individually tailored interdisciplinary interventions based on the use of IGA, and

2) ‘care as usual’. The primary outcome is gait measured by the Gait Deviation Index. Secondary outcome measures are:

walking performance (1-min walk test) and patient-reported outcomes of functional mobility (Pediatric Evaluation of

Disability Inventory), health-related quality of life (The Pediatric Quality of Life Inventory Cerebral Palsy Module) and

overall health, pain and participation (The Pediatric Outcome Data Collection Instrument). The primary endpoint for

assessing the outcome of the two interventions will be 52 weeks after start of intervention. A follow up will also be

performed at 26 weeks; however, exclusively for the patient-reported outcomes.Discussion: To our knowledge, this is the first randomised controlled trial comparing the effects of an individually

tailored interdisciplinary intervention based on the use of IGA versus ‘care as usual’ in children with CP. Consequently,

the study will provide novel evidence for the use of IGA.Trial registration: Trial registration: ClinicalTrials.gov NCT02160457. Registered June 2, 2014.

Keywords: Gait analysis, Cerebral Palsy, Gait Deviation Index, Study protocol

* Correspondence: [email protected] of Orthopaedic Surgery and Traumatology, Odense University

Hospital, Odense, Denmark2Institute of Clinical Research, University of Southern Denmark, Odense,DenmarkFull list of author information is available at the end of the article

© 2015 Rasmussen et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and

reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to

the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver

(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Rasmussen et al. BMC Pediatrics (2015) 15:202 DOI 10.1186/s12887-015-0520-7

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Interventions

Orthopaedic surgery

Control interventionswithout gait analysis report

Local healthcare teamsIndividually tailored interventions

Spasticity management

Physical therapy

Orthotics

Experimental interventionswith gait analysis report

Example: Ankle dorsi flexion

d Too little right dorsiflexion in stance

e too little dorsiflexion in swing.

Test Team A

Retest

Laboratory Team B

Team C

+

+

+

Ganganalyse rapport

14

ResultsRCTmanuscript–DevelopmentalMedicine&ChildNeurology

Lastupdated:18February2018

Figure 1 – Flow diagram of participants in the study

Enr

olm

ent

160 Letters of invitation were sent to eligible children by mail 48 Did not answer

29 Not interested in the study 83 screened by telephone 7 Not interested after screening

16 Not eligible after screening: Orthopaedic surgery (n=5), planned moving (n=3),

diagnosis had changed (n=6) and did not understand Danish (n=2)

60 Baseline assessments

Instrumented gait analysis (n=60), 1-min walk test (n=57) and questionnaires (n=58)

Allo

cati

on

60 Randomised Two participants (one from each group) were randomised with another participant.

30 Allocated to experimental group

30 received individually tailored interdisciplinary intervention with Instrumented gait analysis

provided by 29 different combinations of local healthcare teams.

30 Allocated to control group 30 received individually tailored interdisciplinary intervention without Instrumented gait analysis provided by 29 different combinations of local

healthcare teams.

Fol

low

-up

26 Follow up assessmentsa (26 weeks)

24 participants completed all subscales in the questionnaires



29 Post intervention assessmentsb

(52 weeks – primary follow-up)

IGA (n=28), 1-min walk test (n=24) and all subscales in the questionnaires (n=27)

29 Post intervention assessmentsb (52 weeks – primary follow-up)


Ana

lysi

s

30 Included in the ITT analysis

1-min walk test (n=28) and all subscales of the patient reported outcome (n=29).



Explanations:

Flow chart

15




Enr

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ent







Allo

cati

on






healthcare teams.

Fol

low

-up










Ana

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Explanations:

Flow chart: Enrollment

160

83

60

16

48

29

7

16




Enr

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ent







Allo

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healthcare teams.

Fol

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-up










Ana

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Explanations:

Flow chart: Allocation

60

30 30

17




Enr

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ent







Allo

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on






healthcare teams.

Fol

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-up










Ana

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Explanations:

Flow chart: Allocation

60

30 30

Participants Study II-III

Number, n 60

Age, mean (SD) 6 y 10 m (1 y 3 m)

Sex, girls/boys, n (%) 21/39 (35/65)

CP subtype, UL/BL, n (%) 43/17 (72/28)

GMFCS I / II, n (%) 42/18 (70/30)

18

52 weeks

26 weeks




Enr

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ent







Allo

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on






healthcare teams.

Fol

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-up










Ana

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Explanations:

Flow chart: Follow-up & analysis

26 25

29

30

29

30

2728

19

ResultsBetween-group differences

In favor of Control In favor of Experimental

Rate Change CIlower CIupper Positivt Negativ Pos Neg- - -0.59 [-3.8-2.6] 1 -0,59 -3,8 2,6 -3,21 3,19 3 3 GaitDeviationIndex(GDI) 3 3- - 03.02 [-2.9-8.9] 2 3,2 -2,9 8,9 -6,1 5,7 6 6 1-minutewalktest(metre) 6 6

00.15 [-3.0-3.3] 01.37 [-2.4-5.1] 3 1,37 -2,4 5,1 -3,77 3,73 4 4 PEDI,Functionalskills 4 4-0.57 [-3.8-2.7] -0.93 [-5.5-3.6] 4 -0,93 -5,5 3,6 -4,57 4,53 5 5 PEDI,Caregiverassistance 5 50,175 [-0.8-8.2] 03.26 [-1.9-8.4] 5 3,26 -1,9 8,4 -5,16 5,14 5 5 PedsQL,DailyActivities 5 5-4.41 [-14.3-5.5] 01.12 [-8.7-10.9] 6 1,12 -8,7 10,9 -9,82 9,78 10 10 PedsQL,SchoolActivities 10 10-1.05 [-9.9-7.8] -1.19 [-9.4-7.0] 7 -1,19 -9,4 7 -8,21 8,19 8 8 PedsQL,MovementandBalance 8 8

0,25625 [-0.22-11.6] -7.13 [-15.6-1.3] 8 -7,13 -15,6 1,3 -8,47 8,43 8 8 PedsQL,PainandHurt 8 8-2.47 [-10.6-5.7] -3.41 [-12.5-5.7] 9 -3,41 -12,5 5,7 -9,09 9,11 9 9 PedsQL,Fatigue 9 9-1.81 [-6.9-3.3] 0,134027778 [-4.5-9.9] 10 2,73 -4,5 9,9 -7,23 7,17 7 7 PedsQL,EatingActivities 7 7-0.28 [-4.8-4.2] -2.64 [-8.8-3.5] 11 -2,64 -8,8 3,5 -6,16 6,14 6 6 PedsQL,SpeechandCommunication 6 602.15 [-1.2-5.5] 00.58 [-3.1-4.2] 12 0,58 -3,1 4,2 -3,68 3,62 4 4 PODCI,Globalfunctioningscale 4 401.25 [-3.7-6.2] 04.31 [-0.6-9.2] 13 4,31 -0,6 9,2 -4,91 4,89 5 5 PODCI,Upperextremityfunction 5 501.31 [-1.9-4.6] 0,085416667 [-0.6-3.9] 14 1,63 -0,6 3,9 -2,23 2,27 2 2 PODCI,Transferandbasicmobility 2 2

0,095833333 [-3.1-6.7] 01.52 [-4.7-7.7] 15 1,52 -4,7 7,7 -6,22 6,18 6 6 PODCI,Sportsandphysicalfunctioning 6 603.22 [-4.8-11.2] -5.3 [-14.0-3.4] 16 -5,3 -14 3,4 -8,7 8,7 9 9 PODCI,Pain/ComfortScale 9 902.11 [-5.7-9.9] -3.89 [-13.0-5.2] 17 -3,89 -13 5,2 -9,11 9,09 9 9 PODCI,HappinessScale 9 9

-20 -15 -10 -5 0 5 10 15 20

Gait Deviation Index (GDI) 1-minute walk test (metre) PEDI, Functional skills PEDI, Caregiver assistance PedsQL, Daily Activities PedsQL, School Activities PedsQL, Movement and Balance PedsQL, Pain and Hurt PedsQL, Fatigue PedsQL, Eating Activities PedsQL, Speech and Communication PODCI, Global functioning scale PODCI, Upper extremity function PODCI, Transfer and basic mobility PODCI, Sports and physical functioning PODCI, Pain/Comfort Scale PODCI, Happiness Scale

Rate Change CIlower CIupper Positivt Negativ Pos Neg- - -0.59 [-3.8-2.6] 1 -0,59 -3,8 2,6 -3,21 3,19 3 3 GaitDeviationIndex(GDI) 3 3- - 03.02 [-2.9-8.9] 2 3,2 -2,9 8,9 -6,1 5,7 6 6 1-minutewalktest(metre) 6 6

00.15 [-3.0-3.3] 01.37 [-2.4-5.1] 3 1,37 -2,4 5,1 -3,77 3,73 4 4 PEDI,Functionalskills 4 4-0.57 [-3.8-2.7] -0.93 [-5.5-3.6] 4 -0,93 -5,5 3,6 -4,57 4,53 5 5 PEDI,Caregiverassistance 5 50,175 [-0.8-8.2] 03.26 [-1.9-8.4] 5 3,26 -1,9 8,4 -5,16 5,14 5 5 PedsQL,DailyActivities 5 5-4.41 [-14.3-5.5] 01.12 [-8.7-10.9] 6 1,12 -8,7 10,9 -9,82 9,78 10 10 PedsQL,SchoolActivities 10 10-1.05 [-9.9-7.8] -1.19 [-9.4-7.0] 7 -1,19 -9,4 7 -8,21 8,19 8 8 PedsQL,MovementandBalance 8 8

0,25625 [-0.22-11.6] -7.13 [-15.6-1.3] 8 -7,13 -15,6 1,3 -8,47 8,43 8 8 PedsQL,PainandHurt 8 8-2.47 [-10.6-5.7] -3.41 [-12.5-5.7] 9 -3,41 -12,5 5,7 -9,09 9,11 9 9 PedsQL,Fatigue 9 9-1.81 [-6.9-3.3] 0,134027778 [-4.5-9.9] 10 2,73 -4,5 9,9 -7,23 7,17 7 7 PedsQL,EatingActivities 7 7-0.28 [-4.8-4.2] -2.64 [-8.8-3.5] 11 -2,64 -8,8 3,5 -6,16 6,14 6 6 PedsQL,SpeechandCommunication 6 602.15 [-1.2-5.5] 00.58 [-3.1-4.2] 12 0,58 -3,1 4,2 -3,68 3,62 4 4 PODCI,Globalfunctioningscale 4 401.25 [-3.7-6.2] 04.31 [-0.6-9.2] 13 4,31 -0,6 9,2 -4,91 4,89 5 5 PODCI,Upperextremityfunction 5 501.31 [-1.9-4.6] 0,085416667 [-0.6-3.9] 14 1,63 -0,6 3,9 -2,23 2,27 2 2 PODCI,Transferandbasicmobility 2 2

0,095833333 [-3.1-6.7] 01.52 [-4.7-7.7] 15 1,52 -4,7 7,7 -6,22 6,18 6 6 PODCI,Sportsandphysicalfunctioning 6 603.22 [-4.8-11.2] -5.3 [-14.0-3.4] 16 -5,3 -14 3,4 -8,7 8,7 9 9 PODCI,Pain/ComfortScale 9 902.11 [-5.7-9.9] -3.89 [-13.0-5.2] 17 -3,89 -13 5,2 -9,11 9,09 9 9 PODCI,HappinessScale 9 9

-20 -15 -10 -5 0 5 10 15 20

Gait Deviation Index (GDI) 1-minute walk test (metre) PEDI, Functional skills PEDI, Caregiver assistance PedsQL, Daily Activities PedsQL, School Activities PedsQL, Movement and Balance PedsQL, Pain and Hurt PedsQL, Fatigue PedsQL, Eating Activities PedsQL, Speech and Communication PODCI, Global functioning scale PODCI, Upper extremity function PODCI, Transfer and basic mobility PODCI, Sports and physical functioning PODCI, Pain/Comfort Scale PODCI, Happiness Scale

20

ResultsApplied interventions & compliance

Compliance + Rec + app + Rec

Physiotherapy 24 28

Orthotics 6 10

Spasticity management 5 14

Orthopedic surgery 0 1

Applied interventions Exp CON

Physiotherapy 24 24

Orthotics 8 12

Spasticity management 7 10

Orthopedic surgery 0 1n = 28/29, p = > 0.05

21

ConclusionStudy aimThis study aimed to determine if indivi-dually tailored interdisciplinary interventions with gait analysis lead to greater improvements than individually tailored interdisciplinary intervention without gait analysis in overall gait pat-hology, walking performance and patient-reported outcome measures of function, disability and health-related quality of life.

ConclusionThis study could not confirm the hypo-thesis that improvement in the overall gait pathology, walking performance and patient-reported outcomes following individually tailored interventions when gait analysis is used are superior to those following ‘usual care’ in a case-mix of all children with cerebral palsy at GMFCS levels I and II, at an early age.

Subgroup analysisBetween-group differences

In favor of Control In favor of Experimental

Rate Change CIlower CIupper Positivt Negativ Pos Neg- - -0.59 [-3.8-2.6] 1 GMFCSI- - 03.02 [-2.9-8.9] 2 -0,2 -4,31 3,91 -4,11 4,11 4 5 GaitDeviationIndex(GDI) 4 -5

00.15 [-3.0-3.3] 01.37 [-2.4-5.1] 3 2,69 -3,53 8,91 -6,22 6,22 6 6 1-minutewalk(meter) 6 6-0.57 [-3.8-2.7] -0.93 [-5.5-3.6] 4 0,06 -4,89 5,02 -4,95 4,96 5 5 PEDI,Functionalskills 5 50,175 [-0.8-8.2] 03.26 [-1.9-8.4] 5 1,66 -4,84 8,16 -6,5 6,5 7 7 PEDI,Caregiverassistance 7 7-4.41 [-14.3-5.5] 01.12 [-8.7-10.9] 6-1.05 [-9.9-7.8] -1.19 [-9.4-7.0] 7 GMFCSII

0,25625 [-0.22-11.6] -7.13 [-15.6-1.3] 8 1,24 -6,66 4,2 -7,9 2,96 5 5 GaitDeviationIndex(GDI) 5 -5-2.47 [-10.6-5.7] -3.41 [-12.5-5.7] 9 -3,11 -9,44 15,66 -6,33 18,77 13 13 1-minutewalk(meter) 13 -13-1.81 [-6.9-3.3] 0,134027778 [-4.5-9.9] 10 -2,74 -1,27 6,74 1,47 9,48 4 4 PEDI,Functionalskills 4 -4-0.28 [-4.8-4.2] -2.64 [-8.8-3.5] 11 0,58 -4,2 3,1 -4,78 2,52 4 4 PEDI,Caregiverassistance 4 -402.15 [-1.2-5.5] 00.58 [-3.1-4.2] 1201.25 [-3.7-6.2] 04.31 [-0.6-9.2] 1301.31 [-1.9-4.6] 0,085416667 [-0.6-3.9] 14 0 0

0,095833333 [-3.1-6.7] 01.52 [-4.7-7.7] 15 0 003.22 [-4.8-11.2] -5.3 [-14.0-3.4] 16 0 002.11 [-5.7-9.9] -3.89 [-13.0-5.2] 17 0 0

-3,91-8,91 PEDI,Functionalskills-5,02 PEDI,Caregiverassistance-8,16

-4,2-15,66-6,74-3,1

-20 -15 -10 -5 0 5 10 15 20

GMFCS I Gait Deviation Index (GDI) 1-minute walk (meter) PEDI, Functional skills PEDI, Caregiver assistance

GMFCS II Gait Deviation Index (GDI) 1-minute walk (meter) PEDI, Functional skills PEDI, Caregiver assistance

Rate Change CIlower CIupper Positivt Negativ Pos Neg- - -0.59 [-3.8-2.6] 1 GMFCSI- - 03.02 [-2.9-8.9] 2 -0,2 -4,31 3,91 -4,11 4,11 4 5 GaitDeviationIndex(GDI) 4 -5

00.15 [-3.0-3.3] 01.37 [-2.4-5.1] 3 2,69 -3,53 8,91 -6,22 6,22 6 6 1-minutewalk(meter) 6 6-0.57 [-3.8-2.7] -0.93 [-5.5-3.6] 4 0,06 -4,89 5,02 -4,95 4,96 5 5 PEDI,Functionalskills 5 50,175 [-0.8-8.2] 03.26 [-1.9-8.4] 5 1,66 -4,84 8,16 -6,5 6,5 7 7 PEDI,Caregiverassistance 7 7-4.41 [-14.3-5.5] 01.12 [-8.7-10.9] 6-1.05 [-9.9-7.8] -1.19 [-9.4-7.0] 7 GMFCSII

0,25625 [-0.22-11.6] -7.13 [-15.6-1.3] 8 1,24 -6,66 4,2 -7,9 2,96 5 5 GaitDeviationIndex(GDI) 5 -5-2.47 [-10.6-5.7] -3.41 [-12.5-5.7] 9 -3,11 -9,44 15,66 -6,33 18,77 13 13 1-minutewalk(meter) 13 -13-1.81 [-6.9-3.3] 0,134027778 [-4.5-9.9] 10 -2,74 -1,27 6,74 1,47 9,48 4 4 PEDI,Functionalskills 4 -4-0.28 [-4.8-4.2] -2.64 [-8.8-3.5] 11 0,58 -4,2 3,1 -4,78 2,52 4 4 PEDI,Caregiverassistance 4 -402.15 [-1.2-5.5] 00.58 [-3.1-4.2] 1201.25 [-3.7-6.2] 04.31 [-0.6-9.2] 1301.31 [-1.9-4.6] 0,085416667 [-0.6-3.9] 14 0 0

0,095833333 [-3.1-6.7] 01.52 [-4.7-7.7] 15 0 003.22 [-4.8-11.2] -5.3 [-14.0-3.4] 16 0 002.11 [-5.7-9.9] -3.89 [-13.0-5.2] 17 0 0

-3,91-8,91 PEDI,Functionalskills-5,02 PEDI,Caregiverassistance-8,16

-4,2-15,66-6,74-3,1

-20 -15 -10 -5 0 5 10 15 20

GMFCS I Gait Deviation Index (GDI) 1-minute walk (meter) PEDI, Functional skills PEDI, Caregiver assistance

GMFCS II Gait Deviation Index (GDI) 1-minute walk (meter) PEDI, Functional skills PEDI, Caregiver assistance



















I

II

Age (< vs. > 7 years)CP Subtype (Unilat spastic CP vs. - Bilat spastic CP )

’Responder’Girl - 5.5 years - GMFCS I - FMS: 6-6-6

Baseline 52 weeks

Recommendations

(Control group)

Interventions

- Physiotherapy 1-3 / week- Botulinum toxin

’Non-responder’Boy - 9 years - GMFCS I - FMS: 6-6-6

Baseline 52 weeks

Recommendations

- Follow-up on ROM in ankle- Consider serial casting (if decreasing)

- Physiotherapy

Interventions

- Physiotherapy 2 / week

Height: 132 vs. 140 cm

22

PerspectivesStudy results - Gait analysis

Explorative data - analysis

Christina EsmannMeasure of processes of Care

Gross Motor Function Measure (selected items)

Gait Analysis

Validation of methods used for interpretation

Dissimination of recommendationsAherence to recommendations

44

Study aimThe aim of this study was to investigate the threshold values used by the CPUP by testing the hypothesis that passive range of motion in ankle dorsiflexion is associa-ted with gross motor function and that gross motor function differs between the groups of participants in each category.

Study IIIThresholdvaluesofankledorsiflexionandgrossmotorfunctioninchildrenwithcerebralpalsy–acrosssectionalstudy

1

Title

Thresholdvaluesofankledorsiflexionandgrossmotorfunctioninchildrenwithcerebralpalsy–across-sectionalstudy

HelleMRasmussen1,2,JoachimSvensson2,MariaThorning1,NielsWPedersen1,2,SørenOvergaard1,2,AndersHolsgaard-Larsen1,2.

1DepartmentofOrthopedicSurgeryandTraumatology,OdenseUniversityHospital,Denmark2DepartmentofClinicalResearch,UniversityofSouthernDenmark,Odense,Denmark

Correspondingauthor:HelleMätzkeRasmussen,[email protected]:ActaOrthopedica:http://www.actaorthop.org

Wordcount:3182.

Abstractwordcount:245.

Spelling:AmericanEnglish

Range of motion and clinical cut-off points in ankle dorsiflexion are not correlated with

motor function in children with cerebral palsy – a cross sectional study

H.M. Rasmussen, J. Svensson, M. Thorning, N.W. Pedersen, S. Overgaard, A. Holsgaard-Larsen. Department of Orthopaedic Surgery and Traumatology Odense University Hospital, Odense, Denmark and

Institute of Clinical Research University of Southern Denmark, Odense, Denmark

”Clear” - no indication of deterioration was noted during the examination”.

”Vigilant observation, modified treatment or initiation of treatment is necessary”.

‘‘Alert - treatment is urgently needed, assuming no specific contraindications are present”.

Reference: www.cpup.se

Figure 1 Ankle Dorsiflexion Clinical cut-off points and clinical inter-pretation for the three categories of passi-ve range of motion i ankle dorsiflexion with flexed and extended knee.

Flexed knee

≥20° ≥10

Extended knee

>10° - <20° >0° - <10°

≤10° ≤0°

The Cerebral Palsy follow-up program (CPOP) uses cut-off points (traffic light signals) to categorize passive range of motion (ROM) in: green, yellow and red in order to guide clinical decisions (figure 1).

The cut-off points are not evidence based and potential relationships with gross mo-tor capacity and patient-reported gross motor performance have never been esta-blished.

To investigate passive ROM and the traf-fic light categories for ankle dorsiflexion and their relationships with gross motor capacity and patient-reported gross motor performance in children with cerebral palsy (CP) by testing the hypo-thesis that:- associations between ankle dorsiflexi-on and gross motor capacity/performance exist in children with cerebral palsy.- gross motor capacity/performance differs according to the traffic light categories using passive ankle dorsiflexion.

Material and methods We conducted a cross-sectional study of 60 children with spastic CP at GMFCS levels I-II, aged 5-9 years.

Passive ROM were measured as maximal ankle dorsiflexion with flexed and extended knee using goniometry and the categories applied using the cut-off points provided by CPOP. Furthermore 1-min walking distan-ce (1-min walk), Gross Motor Function Me-asure (GMFM) and Pediatric Quality of Life Inventory Cerebral Palsy Module: move-ment and balance subscale (Pedsql) were collected.

Associations were investigated with Pearson correlation coefficients. Differen-ces in the three groups based on the traffic light categories were investigated with one-way ANOVA.

Results Opposed to our hypothesis no significant correlation (r2 < 0.2, p>0.05) were docu-mented between ROM versus 1-min walk, GMFM and Pedsql (table 1). Furthermore, the group mean values of the outcome measures in the three categories according to ROM did not differ (table 2).

Passive ROM in ankle dorsiflexion is not correlated with gross motor capaci-ty/performance, why the cut-off points used in CPOP are of limited clinical va-lue in relation to gross motor capacity and patient-reported gross motor perfor-mance. As a consequence passive ROM and gross motor capacity/performance may be considered as separate constructs, which may have impact on the decision-making of treatment for the patient group.

Background Aim of study Conclusion

Table 1. Pearson correlation coefficients

Dorsiflexion (knee 90o) r r2 p-value1-min walk test 0.11 0.01 0.41GMFM 0.09 0.01 0.50Pedsql -0.01 0.00 0.96

Dorsiflexion (knee 0o)1-min walk test 0.17 0.03 0.21GMFM 0.09 0.01 0.50Pedsql 0.06 0.03 0.68

Abbriviations: Gross Motor Function Measure (GMFM), Pediatric Quality of Life Inventory Cerebral Palsy Module: movement and balance subscale (Pedsql).

OUH - Odense University Hospital

Table 2. Mean scores (SD) of the three groups and results of the ANOVA.

Dorsiflexion (knee 90o) Green Yellow Red p-valueParticipants n=40 n=6 n=141-min walk test 80 (13) 78 (15) 76 (18) 0.674GMFM 82 (8) 82 (11) 8 (8) 0.975Pedsql 74 (19) 73 (19) 78 (22) 0.744

Dorsiflexion (knee 0o) Green Yellow RedParticipants n=49 n=5 n=61-min walk test 80 (12) 80 (14) 73 (28) 0.529GMFM 82 (8) 82 (11) 83 (8) 0.975Pedsql 74 (20) 84 (20) 70 (16) 0.489

Abbriviations: Gross Motor Function Measure (GMFM), Pediatric Quality of Life Inventory Cerebral Palsy Module: movement and balance subscale (Pedsql).

9

Passive Range of Motion

Alriksson-Schmidt AI et al (2016)Dorsiflexion with extended knee

11

CPOP - Traffic light

Alriksson-Schmidt AI et al (2016)

”Clear and that no indication of deterioration was noted during

assessment”.

>10o

”Yellow indicates that vigilant observation or potentially

treatment is recommended”.

0-10o

“Alert” and that treatment is urgently needed

(assuming no specific ontraindications)”.

<0o

Dorsiflexion with extended knee

10

Interpretation

”For children on GMFCS levels I to III, the threshold values of passive range of motion are set to ensure that the patient is able to dorsiflex adequately in the stance and swing of walking.”

Threshold values

Cerebral Parese Oppfølgingsprogram (CPOP)Alarmverdier for passive bevegeutslag 2014

15

ResultsRange of Motion i ankle dorsiflexion

(Extended knee)

010

2030

40G

ait V

aria

ble

Scor

e an

kle

-20 -10 0 10 20 30 40 50 60Dorsalflexion with extended knee (degree)

Gait variable score

r = -0.3795% CI [-0.57 - -0.13]

4060

8010

012

0G

ait D

evia

tion

Inde

x

-20 -10 0 10 20 30 40 50 60Dorsalflexion with extended knee (degree)

Gait Deviation Index

r = 0.0595% CI [-0.21 - 0.30]

16

4060

80100

120

GDI

Green Yellow Red

ResultsThreshold values - ankle dorsiflexion

(Extended knee)

Gait variable score

010

2030

40gv

s_an

kle

(deg

ree)

Green Yellow Red

Gait Deviation Index

n = 49 n = 5 n = 6 n = 49 n = 5 n = 6

p = 0.02p = 0.6

17

ResultsPassive Range of Motion in ankle dorsiflexion

(Extended knee & Flexion knee)

NO associatio and NO differenceGait Deviation Index

1-minute walkGross Motor Function Measure (selected items)

The Pediatric Quality of Life Inventory CP ModulePediatric Outcome Data Collection Instrument

Association and difference betweenGait Variable Score, ankle

Peak dorsiflexion during gait

19

Study III - ConclusionStudy aimThe aim of this study was to investigate the threshold values used by the CPUP by testing the hypothesis that passive range of motion in ankle dorsiflexion is associa-ted with gross motor function and that gross motor function differs between the groups of participants in each category.

ConclusionPassive range of motion in ankle dor-siflexion is moderately associated with ankle-specific measures of gross motor function, and the mean scores of the ankle-specific measures were different in the three categorical groups. In contrast to our hypothesis, we did not find an important relationship between passive range of motion in ankle dor-siflexion or the three related categories and overall measures of gross motor capacity or the use of gross motor skills in everyday life.

64

Examples - ”traffic light”

High GDI - red valuesGDI: 88.8 Dorsiflexion: 50 / 00

Low GDI - green valuesGDI: 48.9 - GVS: 33.50

Dorsiflexion: 200 / 150

55

Discussion - Perspective

Interpretation of examinations- gait analysis- ROM surveillance Example:Hip surveillance and CPUP hip score- inter- and intra-rater reliability- odds ratio for hip displacement- risk score for hip displacement

27

Thanks!

Participants and their parentsThe local teams and helathcare professionalsResarch assistants & colleguesAcademic advisors and co-authors

University of Southern Denmark, Odense University Hospital Research grant, Region of Southern Denmark Research grant and PhD grant, The Physiotherapy Practice Foundation, The Ludvig and Sara Elsass Foundation, The Linex Foundation and The Danish Physiotherapy Research Fund.

Test Team A

Retest

Laboratory Team B

Team C

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Test Team A

Retest

Laboratory Team B

Team C

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Documents

Ganganalyse til børn med CP - cpop.dk · Ganganalyse til børn med CP – Delresultater fra kliniske forskningsprojekter Helle Mätzke Rasmussen Department of Clinical Research Faculty