Advertisement

Factors Associated With Long-Term Improvement of Gait After Selective Dorsal Rhizotomy

      Highlights

      • Baseline gait quality is related to gait improvement 5 years after SDR.
      • Gait improves more after SDR in children with GMFCS level I and II compared to III.
      • Effects are comparable for children with and without abnormalities on brain MRI.
      • Selective motor control is related to specific improvements in knee kinematics but not to overall gait quality.

      Abstract

      Objective

      To identify factors associated with long-term improvement in gait in children after selective dorsal rhizotomy (SDR).

      Design

      Retrospective cohort study.

      Setting

      University medical center.

      Participants

      Children (N=36) (age 4-13y) with spastic diplegia of Gross Motor Function Classification System (GMFCS) level I (n=14), II (n=15), and III (n=7) were included retrospectively from the database of our hospital. Children underwent SDR between January 1999 and May 2011. Patients were included if they received clinical gait analysis before and 5 years post-SDR, age >4 years at time of SDR and if brain magnetic resonance imaging (MRI) scan was available.

      Intervention

      Selective dorsal rhizotomy.

      Main Outcome Measures

      Overall gait quality was assessed with Edinburgh visual gait score (EVGS), before and 5 years after SDR. In addition, knee and ankle angles at initial contact and midstance were evaluated. To identify predictors for gait improvement, several factors were evaluated including functional mobility level GMFCS, presence of white matter abnormalities on brain MRI, and selective motor control during gait (synergy analysis).

      Results

      Overall gait quality improved after SDR, with a large variation between patients. Multiple linear regression analysis revealed that worse score on EVGS and better GMFCS were independently related to gait improvement. Gait improved more in children with GMFCS I and II compared to III. No differences were observed between children with or without white matter abnormalities on brain MRI. Selective motor control during gait was predictive for improvement of knee angle at initial contact and midstance, but not for EVGS.

      Conclusion

      Functional mobility level and baseline gait quality are both important factors to predict gait outcomes after SDR. If candidates are well selected, SDR can be a successful intervention to improve gait both in children with brain MRI abnormalities as well as other causes of spastic diplegia.

      Keywords

      List of abbreviations:

      BoNT-A (botulinum toxin-A), CP (cerebral palsy), EVGS (Edinburgh Visual Gait Score), GDI (gait deviation index), GMFCS (Gross Motor Function Classification System), HSP (hereditary spastic paraplegia), ITB (intrathecal baclofen), MRI (magnetic resonance imaging), NNMF (non-negative matrix factorization), PVL (periventricular leukomalacia), SDR (selective dorsal rhizotomy), VAF (variance accounted for)
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Himmelmann K.
        • Horber V.
        • De la Cruz J.
        • et al.
        MRI classification system (MRICS) for children with cerebral palsy: development, reliability, and recommendations.
        Dev Med Chil Neurol. 2017; 59: 57-64
        • Graham H.K.
        • Rosenbaum P.
        • Paneth N.
        • et al.
        Cerebral palsy.
        Nat Rev Dis Primers. 2016; 2: 15082
        • Scholtes V.A.
        • Dallmeijer A.J.
        • Becher J.G.
        Can we identify predictors of multilevel botulinum toxin A injections in children with cerebral palsy who walk with a flexed knee pattern?.
        J Child Neurol. 2008; 23: 628-634
        • Steinbok P.
        Selective dorsal rhizotomy for spastic cerebral palsy: a review.
        Childs Nerv Syst. 2007; 23: 981-990
        • Kim H.S.
        • Steinbok P.
        • Wickenheiser D.
        Predictors of poor outcome after selective dorsal rhizotomy in treatment of spastic cerebral palsy.
        Childs Nerv Syst. 2006; 22: 60-66
        • Bolster E.A.
        • van Schie P.E.
        • Becher J.G.
        • van Ouwerkerk W.J.
        • Strijers R.L.
        • Vermeulen R.J.
        Long-term effect of selective dorsal rhizotomy on gross motor function in ambulant children with spastic bilateral cerebral palsy, compared with reference centiles.
        Dev Med Child Neurol. 2013; 55: 610-616
        • Nordmark E.
        • Josenby A.L.
        • Lagergren J.
        • Andersson G.
        • Stromblad L.G.
        • Westbom L.
        Long-term outcomes 5 years after selective dorsal rhizotomy.
        BMC Pediatr. 2008; 8: 54
        • Funk J.F.
        • Panthen A.
        • Bakir M.S.
        • et al.
        Predictors for the benefit of selective dorsal rhizotomy.
        Res Dev Disabil. 2015; 37: 127-134
        • Langerak N.G.
        • Lamberts R.P.
        • Fieggen A.G.
        • et al.
        A prospective gait analysis study in patients with diplegic cerebral palsy 20 years after selective dorsal rhizotomy.
        J Neurosurg Pediatr. 2008; 1: 180-186
        • Langerak N.G.
        • Tam N.
        • Vaughan C.L.
        • Fieggen A.G.
        • Schwartz M.H.
        Gait status 17-26 years after selective dorsal rhizotomy.
        Gait Posture. 2012; 35: 244-249
        • Grunt S.
        • Fieggen A.G.
        • Vermeulen R.J.
        • Becher J.G.
        • Langerak N.G.
        Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature.
        Dev Med Child Neurol. 2014; 56: 302-312
        • Kai M.
        • Yongjie L.
        • Ping Z.
        Long-term results of selective dorsal rhizotomy for hereditary spastic paraparesis.
        J Clin Neurosci. 2014; 21: 116-120
        • Sharma J.
        • Bonfield C.
        • Steinbok P.
        Selective dorsal rhizotomy for hereditary spastic paraparesis in children.
        Childs Nerv Syst. 2016; 32: 1489-1494
        • McFall J.
        • Stewart C.
        • Kidgell V.
        • et al.
        Changes in gait which occur before and during the adolescent growth spurt in children treated by selective dorsal rhizotomy.
        Gait Posture. 2015; 42: 317-322
        • Schwartz M.H.
        • Rozumalski A.
        • Steele K.M.
        Dynamic motor control is associated with treatment outcomes for children with cerebral palsy.
        Dev Med Child Neurol. 2016; 58: 1139-1145
        • Shuman B.R.
        • Schwartz M.H.
        • Steele K.M.
        Electromyography data processing impacts muscle synergies during gait for unimpaired children and children with cerebral palsy.
        Front Comput Neurosci. 2017; 11: 50
        • Steele K.M.
        • Rozumalski A.
        • Schwartz M.H.
        Muscle synergies and complexity of neuromuscular control during gait in cerebral palsy.
        Dev Med Child Neurol. 2015; 57: 1176-1182
        • Grunt S.
        • Becher J.G.
        • van Schie P.
        • van Ouwerkerk W.J.
        • Ahmadi M.
        • Vermeulen R.J.
        Preoperative MRI findings and functional outcome after selective dorsal rhizotomy in children with bilateral spasticity.
        Childs Nerv Syst. 2010; 26: 191-198
        • Dominici N.
        • Ivanenko Y.P.
        • Cappellini G.
        • et al.
        Locomotor primitives in newborn babies and their development.
        Science. 2011; 334: 997-999
        • Grunt S.
        • Henneman W.J.
        • Bakker M.J.
        • et al.
        Effect of selective dorsal rhizotomy on gait in children with bilateral spastic paresis: kinematic and EMG-pattern changes.
        Neuropediatrics. 2010; 41: 209-216
        • Robinson L.W.
        • Clement N.
        • Fullarton M.
        • et al.
        The relationship between the Edinburgh Visual Gait Score, the Gait Profile Score, and GMFCS levels I-III.
        Gait Posture. 2015; 41: 741-743
        • van der Krogt M.
        • Oudenhoven L.M.
        • Buizer A.I.
        • Dallmeijer A.J.
        • Dominici N.
        • Harlaar J.
        The effect of EMG processing choices on muscle synergies before and after BoNT-A treatment in cerebral palsy.
        Gait Posture. 2016; 49: 31
        • Oliveira A.S.
        • Gizzi L.
        • Farina D.
        • Kersting U.G.
        Motor modules of human locomotion: influence of EMG averaging, concatenation, and number of step cycles.
        Front Hum Neurosci. 2014; 8: 335
        • Rethlefsen S.A.
        • Blumstein G.
        • Kay R.M.
        • Dorey F.
        • Wren T.A.
        Prevalence of specific gait abnormalities in children with cerebral palsy revisited: influence of age, prior surgery, and Gross Motor Function Classification System level.
        Dev Med Child Neurol. 2017; 59: 79-88
        • Del Pilar Duque Orozco M.
        • Abousamra O.
        • Church C.
        • et al.
        Reliability and validity of Edinburgh visual gait score as an evaluation tool for children with cerebral palsy.
        Gait Posture. 2016; 49: 14-18