Clinical Orthopaedics and Related Research®

, Volume 470, Issue 5, pp 1320–1326

Case Reports: The Influence of Selective Voluntary Motor Control on Gait After Hamstring Lengthening Surgery

  • Evan J. Goldberg
  • Eileen G. Fowler
  • William L. Oppenheim
Symposium: Current Approaches in Cerebral Palsy, A Focus On Gait Problems

Abstract

Background

Preliminary evidence suggests selective voluntary motor control (SVMC), defined as performance of isolated voluntary joint movement on request, may be an important factor affecting functional movement tasks. Individuals with poor SVMC are unable to dissociate hip and knee synergistic movement during the swing phase of gait and have difficulty extending their knee while the hip is flexing during terminal swing regardless of hamstring length. This pattern may limit their ability to take advantage of hamstring-lengthening surgery (HLS) and may explain a lack of improved stride length postoperatively.

Questions/purposes

Provide a preliminary clinical and conceptual framework for using SVMC to predict swing phase parameters of gait after HLS.

Patients and Methods

We contrasted two patients with spastic diplegia of similar age, gross motor function, and spasticity but with different SVMC scores using the Selective Control Assessment of the Lower Extremity (SCALE). The patients underwent bilateral HLS. Popliteal angles, joint kinematics, step length, stride length, and walking velocity were assessed pre- and postoperatively.

Result

Popliteal angles, terminal knee extension, and knee range of motion improved for both patients. However, only the patient with higher SCALE scores improved stride length postoperatively.

Conclusion

Although preliminary, the data suggest that SVMC, as measured by SCALE, may be a prognostic factor for improved stride length after HLS in patients with spastic diplegia.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

References

  1. 1.
    Arnold AS, Liu MQ, Schwartz MH, Ounpuu S, Dias LS, Delp SL. Do the hamstrings operate at increased muscle-tendon lengths and velocities after surgical lengthening? J Biomech. 2006;39:1498–1506.PubMedCrossRefGoogle Scholar
  2. 2.
    Baumann JU, Ruetsch H, Schurmann K. Distal hamstring lengthening in cerebral palsy. An evaluation by gait analysis. Int Orthop. 1980;3:305–309.PubMedCrossRefGoogle Scholar
  3. 3.
    Carney BT, Oeffinger D, Meo AM. Sagittal knee kinematics after hamstring lengthening. J Pediatr Orthop B. 2006;15:348–350.PubMedCrossRefGoogle Scholar
  4. 4.
    Chicoine MR, Park TS, Vogler GP, Kaufman BA. Predictors of ability to walk after selective dorsal rhizotomy in children with cerebral palsy. Neurosurgery. 1996;38:711–714PubMedCrossRefGoogle Scholar
  5. 5.
    Delp SL, Anderson FC, Arnold AS, Loan P, Habib A, John CT, Guendelman E, Thelen DG. OpenSim: open-source software to create and analyze dynamic simulations of movement. IEEE Transactions on Biomedical Engineering. 2007;54:1940–1950.PubMedCrossRefGoogle Scholar
  6. 6.
    Delp SL, Arnold AS, Speers RA, Moore CA. Hamstrings and psoas lengths during normal and crouch gait: implications for muscle-tendon surgery. J Orthop Res. 1996;14:144–151.PubMedCrossRefGoogle Scholar
  7. 7.
    Engsberg JR, Ross SA, Collins DR, Park TS. Predicting functional change from preintervention measures in selective dorsal rhizotomy. J Neurosurg. 2007;106:282–287.PubMedGoogle Scholar
  8. 8.
    Fowler EG, Goldberg EJ. The effect of lower extremity selective voluntary motor control on interjoint coordination during gait in children with spastic diplegic cerebral palsy. Gait Posture. 2009;29:102–107.PubMedCrossRefGoogle Scholar
  9. 9.
    Fowler EG, Staudt LA, Greenberg MB, Oppenheim WL. Selective Control Assessment of the Lower Extremity (SCALE): development, validation, and interrater reliability of a clinical tool for patients with cerebral palsy. Dev Med Child Neurol. 2009;51:607–614.PubMedCrossRefGoogle Scholar
  10. 10.
    Gage JR. Surgical treatment of knee dysfunction in cerebral palsy. Clin Orthop Relat Res. 1990;253:45–54.PubMedGoogle Scholar
  11. 11.
    Gold GE, Asakawa DS, Blemker SS, Delp SL. Magnetic resonance imaging findings after rectus femoris transfer surgery. Skeletal Radiol. 2004;33:34–40.PubMedCrossRefGoogle Scholar
  12. 12.
    Hof AL. Scaling gait data to body size. Gait Posture. 1996;4:222–223.CrossRefGoogle Scholar
  13. 13.
    Horstmann HM, Bleck EE. Orthopaedic Management in Cerebral Palsy. 2nd ed. London: Blackwell Publishing; 2007.Google Scholar
  14. 14.
    Nene AV, Evans GA, Patrick JH. Simultaneous multiple operations for spastic diplegia. Outcome and functional assessment of walking in 18 patients. J Bone Joint Surg Br. 1993;75:488–494.PubMedGoogle Scholar
  15. 15.
    Ostensjo S, Carlberg EB, Vollestad NK. Motor impairments in young children with cerebral palsy: relationship to gross motor function and everyday activities. Dev Med Child Neurol. 2004;46:580–589.PubMedCrossRefGoogle Scholar
  16. 16.
    Peacock WJ, Staudt LA. Functional outcomes following selective posterior rhizotomy in children with cerebral palsy. J Neurosurg. 1991;74:380–385.PubMedCrossRefGoogle Scholar
  17. 17.
    Sanger TD, Chen D, Delgado MR, Gaebler-Spira D, Hallett M, Mink JW and the Taskforce on Childhood Motor Disorders. Definition and classification of negative motor signs in childhood. Pediatrics. 2006;118:2159–2167.PubMedCrossRefGoogle Scholar
  18. 18.
    Staudt LA, Peacock W. Selective posterior rhizotomy for the treatment of spastic cerebral palsy. Pediatric Physical Therapy. 1989;1:3–9.CrossRefGoogle Scholar
  19. 19.
    Thometz J, Simon S, Rosenthal R. The effect on gait of lengthening of the medial hamstrings in cerebral palsy. J Bone Joint Surg Am. 1989;71:345–353.PubMedGoogle Scholar
  20. 20.
    van der Linden ML, Aitchison AM, Hazlewood ME, Hillman SJ, Robb JE. Effects of surgical lengthening of the hamstrings without a concomitant distal rectus femoris transfer in ambulant patients with cerebral palsy. J Pediatr Orthop. 2003;23:308–313.PubMedCrossRefGoogle Scholar
  21. 21.
    Voorman JM, Dallmeijer AJ, Knol DL, Lankhorst GJ, Becher JG. Prospective longitudinal study of gross motor function in children with cerebral palsy. Arch Phys Med Rehabil. 2007;88:871–876.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Evan J. Goldberg
    • 1
  • Eileen G. Fowler
    • 1
  • William L. Oppenheim
    • 1
  1. 1.UCLA/Orthopaedic Hospital Center for Cerebral PalsyDavid Geffen School of Medicine at UCLALos AngelesUSA

Personalised recommendations