A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy

Abstract

A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy A randomized controlled single-blind trial was performed to compare lumbo-sacral selective posterior rhizotomy (SPR) followed by intensive physiotherapy, with intensive physiotherapy alone in improving motor function in children with spastic diplegic cerebral palsy. Fifteen patients were randomly assigned to each treatment modality. Patients in the SPR group had rhizotomy within 1 month, followed by intensive outpatient physiotherapy for 9 months. Patients assigned to physiotherapy alone had identical intensive physiotherapy. There was a statistically significant and clinically important difference in improvement in motor function in favor of the SPR group, with a mean increase in total Gross Motor Function Measure (GIMFM) score of 11.3% at 9 months for the SPR group compared with 5.2% for the physiotherapy-only group (P=O.OW) . Significant improvements in spasticity (P<O.OOl) and range of movement (P<O.OOl) were noted in the SPR group compared to the physiotherapy-only group. The results indicate that the improvement in motor function after SPR is more than can be explained by the associated intensive physiotherapy.Selective posterior 14iizotomy (SPR) is currently perfoi-nietl in many centcis for tlie treiitment ofsl,:isticity asoriatetl with wre1)raI palsy (C'P). with the u i i n of rctlucing spasticity i i~i t l increiising range of movenient iii tlic lower liinbti. with the t*sl)ectatioii tliilt this will improve tlie motor fiinction of the child. Ft~vorable results liiive b w n iq)orted after this operation by inany workers in the fic4tl ( F no iiioiitlisaftei.ti,catineiit.The total score of the Gross Motor Fiinctioii Aletisure ((:;\I FJI) \vas chosen as tlie primary outcome meas\ire for this study bec*ause it was the only fiiiictional assessment tool that l i d becn stantlaidizecl antl \ditlatetl for use in chiltli~n with sl'astic('P(llusse1lct HI. 1989 , Haleyet al. 1991).The study was eontluctetl at British ('olumbia's C'hiltlren's Hospital. t lie only tertiary rare refel-ral c~hiltlreii's hospitiil i n the piwince of British (401i~nibia.Ttie study was approved by tlie Etliics('oaimitt~eoft1ic University of British C'olumbia.Fifteen chiltliwi were raiitlomly assigned to each w i n oft he st iidy. One child in eavh group tlropped out after rantlomization: the parents of one cliiltl nssignetl to tlie pliysiotIieiq>y-only group tlecitletl that they w e r~ not l)reparetl to wait for surgery later. iintl tlie ~~ar~iitsoftlieotliercliiltl assigned to the SPR group later irfiisetl rhizotoiny. C'hiltlren in theSPR group , ranged i n tige froiii 35 to 75 months (mean 50 montlis. median 47 months), antl in the coiitrol gi-oup from 35 to 77 months (iiiean 47 months. median 42 nionths).Sis children \vho were potentially eligible were not entered into the study, but \vent on to undergo a rhimtomy Three of these patients did not meet all tlie eligibility cr...

Changes in synergistic movement patterns after selective dorsal rhizotomy

“…Steinbok et al (1997) have shown increased improvements in the GMFM, spasticity, and range of movement in children having both SDR and intensive physical therapy. However, they did not find increased improvements in physiological cost index, strength, the Peabody Fine Motor Scale (Folio and Fewell 1983), or in the self-care assessment score (Steinbok et al 1997). Increased improvements in GMFM, tone, active range of motion, passive range of motion, and some gait parameters were also found by Wright et al (1998).…”

“…However, it is debated as to whether a reduction in spasticity improves function (Landau 1974, Sahrmann and Norton 1977, Landau and Hunt 1990, McLaughlin et al 1994. In two separate randomized clinical trials, Steinbok et al (1997) and Wright et al (1998) have found significant functional improvements, as measured by the Gross Motor Function Measure (GMFM, Russell et al 1989), in children undergoing SDR and intensive physical therapy compared with children having intensive physical therapy only. However, in a similar study, McLaughlin et al (1998) found no such improvements.…”

“…The spectrum of views concerning the relation between synergistic patterns and spasticity ranges from the view that they are totally unrelated (Landau 1974, Landau andHunt 1990) to the view that the disorders are fundamentally related (Bobath 1990). Most investigators agree that immediately after selective dorsal rhizotomy (SDR), spasticity is greatly reduced (Steinbok et al 1997, McLaughlin et al 1998, Wright et al 1998. However, it is debated as to whether a reduction in spasticity improves function (Landau 1974, Sahrmann and Norton 1977, Landau and Hunt 1990, McLaughlin et al 1994.…”

Selective dorsal rhizotomy for spasticity not associated with cerebral palsy: reconsideration of surgical inclusion criteria

“…Overall results in this study were characterized as consistent with previously published results of SDR for spastic diplegia in randomized controlled trials. 20,21,34,37 …”

Functional decline in children undergoing selective dorsal rhizotomy after age 10

“…It is thus clear that SDR is much more likely to be appropriate in early childhood. Two of the classic studies of the efficacy of SDR 5,6 were limited to children below 7 years old and showed improvement in gross motor function whereas a third study 7 which extended to 18 years showed only marginal improvement. The current study by MacWilliams et al would appear to confirm that SDR is generally inappropriate in later childhood and adolescence when other factors are more important than spasticity.…”