Comparison of Motor Outcomes after Selective Dorsal Rhizotomy with and without Preoperative Intensified Physiotherapy in Children with Spastic Diplegic Cerebral Palsy

Abstract

A previous randomized clinical trial compared selective dorsal rhizotomy (SDR) plus postoperative intensified physiotherapy (group 1) with intensified physiotherapy alone (group 2) for children with spastic diplegic cerebral palsy. At the end of this trial, all patients in group 2 had an SDR, followed by further intensified physiotherapy. This study was performed to determine if the additional intensified physiotherapy before SDR, as occurred in group 2, improved long-term motor outcome. Outcomes were compared in the two groups, i.e. group 1 without intensified physiotherapy before SDR and group 2 with intensified physiotherapy before SDR. The primary outcome measure was the Gross Motor Function Measure (GMFM). Lower-limb spasticity, range and strength were secondary outcome measures. Baseline assessments had been done for the prior clinical trial. For this study, patients were reassessed by physiotherapists blinded to the treatment group. Thirteen children in each group were studied at a mean follow-up of 53 months. The mean improvement in GMFM was 10.0 in group 1 and 10.4 in group 2 (p = 0.9). Improvements in spasticity and range were similar in the two groups. There was no significant change in muscle strength in either group. It was concluded that in this relatively small series of patients, additional intensified physiotherapy before SDR did not improve motor outcomes.

Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature

“…None of these articles was classified as level I or V; five articles were rated as level II, 13 as level III, and 34 as level IV . Table gives an overview of the background information, while Table reports the results of the appraisal of the selected level II and level III articles.…”

“…Table gives an overview of the background information, while Table reports the results of the appraisal of the selected level II and level III articles. The quality of the actual conduct of the studies was rated as strong in one study, moderate in 13 studies, and weak in four studies . Table shows an overview of the answers given for the four research questions regarding the description of selection criteria for SDR for evidence levels II to IV.…”

“…None of the studies provided a detailed description for all SDR selection criteria. However, 11 studies (21%; three level II studies and eight level IV studies) provided a partly detailed description of a single selection criterion . Most studies described how strength should be assessed on a functional level and provided the description of specific gross motor tasks such as high‐kneeling, squatting, sitting, standing, or walking while other studies described how motor control should be assessed …”

A systematic review finds that methodological quality is better than its reputation but can be improved in physiotherapy trials in childhood cerebral palsy

“…Another six studies [20,22,25,27,29,30] were performed in a single center, whereas three studies (21%) [21,24,28] did not describe their setting at all. A sufficiently detailed description of the sampling frame was given in 8 out of 14 studies (57%) [3,4,18,19,22,23,27,29] to allow an interpretation of the results and a transfer to other settings; in two studies (14%) [25,26] the description was partly reproducible and four studies (29%) [20,21,24,28] did not provide any information.…”

“…Four studies [3,18,19,23] exclusively used activity outcomes such as Gross Motor Function Measurement (GMFM), whereas three studies [21,22] limited their assessment to structural or functional outcomes (such as bone density or muscle strength) only, components that do not provide information on clinical relevance [11]. Two studies (one a follow-up publication [30] and one with behavioral and psychological outcomes only [27]) were excluded.…”