PREDICTIVE FACTOR OF OUTCOME SINGLE EVENT MULTILEVEL SURGERY IN

SPASTIC DIPLEGIC CEREBRAL PALSY AT PROF. DR.dr.R.SOEHARSO

ORTHOPEDIC HOSPITAL

SURAKARTA

dr.Dimas Febriarto *

dr. Anung B Satriadi,Sp. OT (K) **

dr. Agus Priyono, Sp. OT (K) ***

Orthopaedic & Traumatology Faculty of Medicine Sebelas Maret University-

Prof.Dr.dr.R.Soeharso Orthopaedic Hospital,Solo

2014

PREDICTIVE FACTOR OF OUTCOME SINGLE EVENT MULTILEVEL SURGERY IN

SPASTIC DIPLEGIC CEREBRAL PALSY AT PROF. DR.dr.R.SOEHARSO

ORTHOPEDIC HOSPITAL

SURAKARTA

(Final Paper)

Dimas Febriarto*Anung Budi Satriadi**Agus Priyono**

*Resident of Orthopaedic & Traumatology Faculty of Medicine,

Sebelas Maret University

**Departement of Orthopaedic & Traumatology Faculty of Medicine,

Sebelas Maret University-Soeharso Orthopaedic Hospital,Solo

Background. Single Event Multi Level Surgery (SEMLS) is commonly performed to corrected

orthopaedic deformities and improve function in children with Spastic Diplegic Cerebral Palsy.

Problems in developing such as poverty, poor hospital acces, poor education and noncompliance

are factors that affect the success outcome of SEMLS. The purpose of this study was to examine

the patient characteristic and demographic factor related to predictive of outcome in patient with

SEMLS

Method. This study based on cross sectional of 55 patients (28 male, 22 female) children with

Spastic Diplegic Cerebral Palsy treated by SEMLS at pediatric clinic department of Soeharso

Orthopaedic Hospital Surakarta at least 6 month follow up, since January 2012 until Juny 2014.

The patients characteristics at the time of presentation, such as the initial age and severity of

initiation of operation, educational and economical level of the parents, access to the hospital and

control compliance, were examined with use of linear regression analysis modeling in relation to

functional outcome measure with GMFCS Score

Result : Compliance control was significant relationship with predictive outcome SEMLS. Other

predictive factor, such as initial age and severity of spasticity, parental or caregiver educational

and economical level, and access to the hospital no significant relationship was found with

outcome of SEMLS

Conclusion : Compliance control of the patient parent treatment are the most factor related for

the predictive outcome of SEMLS

Keyword : SEMLS, CP Spastic Diplegic, factor predictive of outcome

PREDICTIVE FACTOR OF OUTCOME SINGLE EVENT MULTI LEVEL SURGERY FOR

CEREBRAL PALSY SPASTIC DIPLEGIC di RS ORTHOPEDI PROF.

DR.dr.R.SOEHARSO SURAKARTA

(Final Paper)

Dimas Febriarto*Anung Budi Satriadi**Agus Priyono**

*Residen Orthopaedi&Traumatologi Fakultas Kedokteran,

Universitas Sebelas Maret

**Fakultas Kedokteran Bagian Orthopaedi & Traumatologi,

Universitas Sebelas Maret, Rumah Sakit Orthopaedi Soeharso Prof.dr.R.Soeharso,Solo

Latar Belakang. Single Event Multi Level Surgery (SEMLS) merupakan penanganan yang

paling sering digunakan untuk memperbaiki deformitas dan fungsional pada anak dengan

Cerebral Palsy Spastik Diplegik. Permasalahan pada Negara berkembang berupa kemiskinan,

akses ke rumah sakit yang sulit, kurangnya pendidikan dan ketidakpatuhan, merupakan faktor-

faktor yang berpengaruh terhadap keberhasilan outcome pada SEMLS. Tujuan penelitian ini

adalah mengetahui hubungan faktor karakter pasien dan demografi dengan predictive of outcome

pada pasien dengan SEMLS

Metode. Penelitian menggunakan studi cross sectional pada 55 (28 laki-laki, 22 wanita) anak

penderita Cerebral Palsy Spastik Diplegik yang dilakukan SEMLS pada klinik pediatrik rumah

sakit Ortopaedi Prof.dr.R.Soeharso Surakarta paling sedikit 6 bulan, sejak Januari 2012 hingga

November 2013. Karakteristik pasien saat dilakukan pemeriksaan adalah usia dan derajat

keparahan saat sebelum dilakukan terapi, tingkat pendidikan dan ekonomi orang tua, akses ke

rumah sakit dan kepatuhan kontrol ke rumah sakit, kemudian dilakukan pemeriksaan analisa

dengan model regresi linier untuk mengetahui hubungan functional outcome SEMLS

menggunakan GMFCS Score

Hasil: Kepatuhan kontrol merupakan faktor yang paling berpengaruh terhadap outcome SEMLS,

sedangkan faktor-faktor prediksi lainnya seperti faktor usia, derajat keparahan (spastisitas),

tingkat pendidikan, ekonomi, dan kemudahan akses ke rumah sakit tidak berpengaruh secara

signifikan terhadap outcome dari SEMLS

Kesimpulan. Kepatuhan kontrol orangtua merupakan faktor yang paling berpengaruh terhadap

predictive outcome SEMLS.

Kata Kunci : SEMLS, CP Spastik Diplegik, factor predictive of outcome

Introduction

Cerebral Palsy is a group of non-progressive disorder that occurs in early

childhood where the brain abnormality causing disturbances in the movement and

postural function.1

In developing countries the prevalence of Cerebral Palsy (CP) was 2 to 2.5 per

1,000 births. CP spastic type is the most common sub-type, which is nearly 70% - 80% of

the whole population of CP. Patients experiencing spasticity involving the lower

extremities with minor motoric disorders in the upper extremities, but most of them still

able to walk, either usingc tools or not.2

In the 1980s, orthopedic therapy in children with Cerebral Palsy performed

surgical procedures on an annual basis, which is often referred to Happy birthday

syndrome. Rang probably was the first to propose methods of intervention operations at

some level anatomy at one stage. Single-event multilevel surgery (SEMLS) is a

corrective methode in the form of operation of the soft tissue and bone, with two or more

different anatomical locations at the same time with the aim of rehabilitation can be done

in one time.4

Research conducted by Bleck and Rang, Silver and Dela Garza showed that the

surgical therapy to correct joints with different anatomical locations in a single step

(Single Event Multi level Surgery) showed effective results than multi stages surgery.

Previous studies have shown that walking ability in children peaked at the age of seven

years. So the ideal time for surgery is the age of seven years old.4

Some problematic in the poor and developing countries such as poverty, lack of

education and limitation of the healthcare facilities, lack of compliance for control and

rehabilitation, lack of adequate medical attention causing delayed treatment to Cerebral

Palsy patients, thus greatly affect the outcome of the CP therapy.5

This study aimed to investigate the characteristics of patients with Spastic

Diplegic Cerebral Palsy and to evaluate the predictive outcome in patients with Spastic

diplegic Cerebral Palsy who came to the Paediatric Clinic RSO Prof. Dr. dr. R. Soeharso

Surakarta after Single Event Multilevel Surgery method performed in Paediatrics clinic at

RSO Prof. Dr. dr. R. Soeharso Surakarta.

Methods

This is observational study with cross-sectional design. This study was held at

pediatrics clinic at RSO Prof.Dr.dr.R.Soeharso Surakarta on January 1st – November 1st

2013. Population and sample of this study was all Cerebral Palsy Spastic Diplegic

patients who came to pediatrics clinic at RSO Prof.Dr.dr.R.Soeharso Surakarta, with

inclusion criteria patients with Cerebral Palsy Spastic Diplegic who had perfomed

SEMLS method, Patients who had peformed SEMLS operation after minimal 6 month.

Exclusion criteria . Drop out during the therapy, Uncompleted criteria, Patients refuse to

became sample of the study. This study based on cross sectional of 55 patients (28 male,

22 female) children with Spastic Diplegic Cerebral Palsy treated by SEMLS at pediatric

clinic department of Soeharso Orthopaedic Hospital Surakarta at least 6 month follow up,

since January 2012 until Juny 2014. The patients characteristics at the time of

presentation, such as the initial age and severity of initiation of operation, educational and

economical level of the parents, access to the hospital and control compliance, were

examined with use of linear regression analysis modeling in relation to functional

outcome measure with GMFCS Score

Results

From our study that being held at pediatric clinic of RSO Prof.Dr. dr. R.Soeharso

Surakarta, between January 1st – November 1st 2013, we obtained 50 patients with

distribution as followings:

28 male patients (56%) and 22 female patients (44%).

0

20

40

male female

28 (56%)22 (44%)

Sex Distribution Percentage

male

female

21

22

23

24

25

26

27

under 7 yearsold

over 7 years old

23 (46%)

27 (54%)

Age Distribution

under 7 years old

over 7 years old

0

5

10

15

20

25

30

0 1 2 3 4

0

2426

0 0

Severity Level Distribution

0

10

20

30

40

50

comply not comply

48 (96%)

2 (4%)

patients Distribution based on compliance

comply

not comply

0

5

10

15

20

25

30

easy uneasy

30 (60%)

20 (40%)

Easiness acces to hospital

easy

uneasy

0

5

10

15

20

25

30

35

highschool andabove

under highschool

19 (38%)

31 (62%)

Parents level of education Distribution

highschool and above

under highschool

0

10

20

30

well off needy

20 (40%)

30 (60%)

Parents’s economic level

well off

needy

0

5

10

15

20

25

30

35

40

45

1 2 3 4 5

0

9

41

0 0

Patients Distribution based on Outcomes

Discussion

Table 1. Results analysis of the Partial (Individual) predictive factors influence Against Outcome

(GMFCS Score).

Model Beta Sig.

Age -0.61 0.714

Severity 0.072 0..638

Compliance control -0.200 0.020*

Acces easiness to hospital 0.204 0.199

Parents education -0.308 0.161

Parents economic status 0.091 0.678

Note : Sig > 0.05, there’s significancy between variables

According to the table number 2 shows that the effect of compliance in control for the

rehabilitation to the outcomes using multiple linear regression analysis showed

significance 0.02 (less than 0.05) These results indicate that the compliance control for

rehabilitation significantly influence the outcome. Beta constant value is -0.200. The

negative sign indicates that the more frequent the control was, the better outcome will be

obtained. The magnitude of the effect of compliance controls for the rehabilitation of the

outcome was 20%. According to Biwott (2014), the compliance of the patients to control

would make them remain consistent to exercise regularly as recommended by the doctor

so that will affect the outcome.

Table 2. result of data analysis on the influence of control compliance to the Outcome

Model B Sig.

Control compliance -0.200 0.020

Note : Sig > 0.05, there’s significancy between variables

Based on Table 3 showed that the odds ratio value indicated by the value "Estimate" is

0.200 mean: patients who had good compliance had more risk to have 0.20 times better

outcomes than patients who didn’t have good compliance control. Asymp value. Sig (2-

Sided) shows the p value or significance of the value of the odds ratio. When <0.05 then

the level of 95%, odds ratio was significant or meaningful meaning it can represent the

entire population. Value of the Common Odds Ratio Lower Bound and Upper Bound

showed the upper limit and lower limit odds ratio, which means: at least patients who had

good compliance had at least 0.200 times better outcome results and the untill to 3.541

times better outcome results compared to non-compliance patients.

Table 3. analyisis data results of the Odds Ratio of the influence on compliance control to

the Outcome

Estimate Asymp.Sig.(2-side) Common Odds-Ratio

Lower Bound Upper Bound

0.200 0.0272 0.011 3.541

Compliance control had significant relationship with predictive outcome of

SEMLS. Other predictive factor, such as initial age and severity of spasticity, parental or

caregiver educational and economical level, and access to the hospital had no significant

relationship with outcome of SEMLS .

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