Effectiveness of instrumented gait analysis in interdisciplinary interventions on parents’ perception of family-centered service and on gross motor function in children with cerebral palsy: a randomized controlled trial

Background Children with cerebral palsy often exhibit an altered gait pattern; however, it is uncertain whether the use of an instrumented gait analysis in interdisciplinary interventions affects the perceived experience of family-centered service (FCS) and/or gross motor function. The aim of this study is to investigate whether individually tailored interdisciplinary interventions, based on an instrumented gait analysis report, has a superior effectiveness on perceived FCS and gross motor function in children with cerebral palsy, compared to ‘care as usual’ without the use of instrumented gait analysis. Furthermore, to investigate potential associations between perceived FCS and gross motor function improvement with the goal of improving future therapy on gross motor function. Method This is a sequel analysis on tertiary outcome measures from a prospective, single blind, randomized, parallel group study including two groups of 30 children aged 5–8 years with spastic cerebral palsy at Gross Motor Function Classification System levels I-II (n = 60). The intervention group underwent a three-dimensional gait analysis, from which a clinical report was written with recommendations on interdisciplinary interventions, such as physical therapy, orthopedic surgery, orthotics or spasticity management. To assess effectiveness on perceived FCS and gross motor function, at baseline, 26 weeks and 52 weeks, the five domains in the Measure of Processes of Care (MPOC-20) (Enabling and partnership, Providing general information, Providing specific information about the child, Respectful and supportive service, and Coordinated and comprehensive care) and the Gross Motor Function Measurement (GMFM-66) were used as outcome measures. Results No significant differences in between-group change scores in any of the five MPOC-20 domains were observed (p = 0.40–0.97). In favor of the intervention group a significantly higher between-group change score in GMFM-66 (mean difference: 3.05 [95%CI: 1.12–4.98], p = 0.003) after 52 weeks was observed. Conclusion The addition of an instrumented gait analysis report to ‘care as usual’ did not improve the parents’ perceptions of FCS in treatment of children with cerebral palsy. However, superior improvement in the GMFM-66 was observed in the intervention group, suggesting meaningful gross motor function improvement. Trial registration Clinical Trials, NCT02160457. Registered June 10th 2014.


The report describes:
-Body functions and structure impairments that are believed to affect walking.
-The elements of the child's gait (Features), where the movement pattern differs from the movement pattern in children without disabilities. The elements are documented as deviations in the course of the curve over movements of the pelvis, hip, knee and ankle.
-Additional information used in the interpretation of the survey results (e.g. physical examination, functional test and questionnaires).

The report
The report contains the following sections: -Relevant history and other measures -Child's height, weight, walking speed, stride cadence, font length (Orientation) -Gait index describing movements' deviation from gait in children without disabilities (GDI, GPS and GVS).
-Description of the quality of the study (Quality) -Comparison of study findings and supplementary information, as well as interpretation of impairments affecting time (Evidence and interpretation) -Graphs of the child's movements during the course of marking survey findings (Gait Data and Consistency plots) -Description of survey findings (Description) -The physical examination and information on walking speed, stride length etc. (Physical examination and temporal-spatial parameters).
-Results of functional tests and questionnaires (Other measures) The report will be conferred interdisciplinary as part of a research project. Thereafter, on the basis of the examination findings, an overall description of relevant contributions that health personnel are recommended to consider, will be prepared.  (2010) 3

Notes on reading this report
The rest of this report outlines the evidence in support of the findings listed above. The Orientation and Quality sections should be read first as they may contain information that is pertinent to how the data is interpreted. For each of the impairments identified there is a box in the Evidence section that lists gait features and elements of the clinical exam and other data that have been linked to that specific impairment. The final section outlines the symbols used to mark up specific features on the gait graphs. The report should be read alongside a version of the data on which the features have been marked.
The report is based on the first of two 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.

Relevant history
The child is followed in the Cerebral Palsy Follow-up program at XXX and by PT XXX The child walks with a drop-foot orthotic, that he/she is pleased with. The child has a lumbar scoliosis. The child's mother tells that the child's goal is to learn to ride a 2-wheel bicycle. Pelvic int rot 5,3

Other measures
Hip int rot 18,6 13,0 Foot prog 9,2 6,5 Comments on video -The child stands with weight bearing primarily on her left leg and with the right leg in slight flexion. Leg length discrepancy is visual on the frontal video in stance, in both knee and pelvic. Visually it seems more pronounced than the measured 1.5 cm. -The child walks a bit unsecure, which is seen in the end of the frontal video, where she/he changes direction and loses balance. The child walks with the leg in adduction and often crosses the midline. The child holds his/her right arm in a position with light flexion in the elbow. When the child walks with shoes and orthotics, gait is more secure and faster. Furthermore the child walks with heel strike.

Quality
Is the data likely to be representative of the subject's usual walking pattern? -The child's mother confirms that the walking pattern is representative of the normal walking pattern Are there any concerns regarding consistency of traces? -No, but there is some inconsistency in the transverse plane.

Features:
Comments: Too little dorsiflexion in swing (k) is seen due to reduced strength in dorsiflexion, which causes the increased knee flexion in late swing (i). The decrease in dorsiflexion in midstance (j) might also be due to decreased range of movement in dorsiflexion (8° / 10°).
Increased pelvic rotation (c) and increased knee flexion in early stance (g) might also be a compensatory effect for decreased push-off in plantar flexion (plantar flexor strength). This report was prepared on the basis of a gait analysis that was carried out as part of the research project: "Individual multidisciplinary intervention". The report is prepared in English, but also includes a short summary in Danish containing the most important findings (this section has been removed).

The report describes:
-Body functions and structure impairments that are believed to affect walking.
-The elements of the child's gait (Features), where the movement pattern differs from the movement pattern in children without disabilities. The elements are documented as deviations in the course of the curve over movements of the pelvis, hip, knee and ankle. -Additional information used in the interpretation of the survey results (e.g. physical examination, functional test and questionnaires).

Multidisciplinary recommendations
The recommendations have been made based on a review of the report on xx-xx-xxxx by an interdisciplinary team: The multidisciplinary team consisted of:

Detailed description
The study on xx-xx-xxxx in the Gait Analysis Laboratory shows that the gait pattern, i.e. the way the child moves his/her joints in the legs during walking is affected by the following: -Reduced joint mobility in the right knee, which is not fully extended.
-Reduced muscle strength around the right ankle -Reduced joint movement in right foot lift (dorsal flexion) -Leg length difference (measured at x cm for the study) Furthermore, the examination shows that when the child walks with drop foot brace / orthotics, gait is more secure and faster. The child walks with heel strike on both feet.
The child attends CPOP controls at the XXX Hospital. A right convex scoliosis has been observed.

Intervention recommendations
Interventions based on the observed functional impairments Based on the findings of the gait study, the following actions are recommended: Reduced joint mobility in right knee and leg length difference -Orthopedic surgical assessment of efforts to improve joint mobility of the right knee joint, and assessment of the leg length difference.
Reduced strength around the right ankle joint -Exercises to improve muscle function in lifting the forefoot (dorsal flexion) and heel lift (plantar flexion) on the right leg so as to improve lifting of the forefoot in the swing phase and at foot contact during walking. -Continuous use of the drop foot brace/orthotics.

Reduced joint movement in the right foot lift
-Exercise efforts to maintain muscle length around the right ankle, so as to maintain current joint mobility Dato xx-xx-xxxx

Interventions based on the observed functional impairments
Based on the findings of the gait study, the following actions are recommended: Reduced joint mobility in right knee and leg length difference -Orthopedic surgical assessment of efforts to maintain and improve joint mobility of the right knee joint, as well as assessment of leg length discrepancy (note, the child has a right convex lumbar scoliosis). -At the interdisciplinary conference various operations were discussed, but it is agreed that a precise recommendation must depend on the clinical examination and possibly supplementary examinations. The orthopedic surgeon is asked to make a decision on the further plan, as well as inform the family of the need for further examinations and treatment options.
Reduced strength around the right ankle joint -Exercises to improve muscle function in lifting the forefoot (dorsal flexion), with flexed hip and knee (as in the middle of the swing phase) as well as with a stretched knee (as at the end of the swing phase), where the right foot is held at an approx. 5-10 degree plantar flexion. The action should be primarily focused on concentric and isometric muscle strength in the tibialis anterior with the flexed and extended knee. -Exercise efforts to improve muscle function in heel lift (plantar flexion) on the right leg to improve push-off. The training should have a special focus on plantar flexion with extended hip and knee, as at the end of the standing phase.
Reduced joint movement in the right foot lift -Exercise efforts to maintain muscle length around the right ankle, so as to maintain current joint mobility