An Evidence-Based Review of

Physical Therapy Intervention for

Individuals Who Have Undergone a

Selective Dorsal Rhizotomy

Caroline Colvin, PT, DPT, PCS

Molly Thomas, PT, DPT, PCS

Objectives

• Describe current practice in physical therapy (PT)

management of patients following SDR (selective dorsal

rhizotomy)

• Identify evidence-based recommendations for clinical

assessments before and after SDR

• Select evidence-based therapeutic interventions and dosing

related to PT before and after SDR

• Discuss future research needs related to PT following SDR

Disclosure Information

AACPDM 72nd Annual Meeting | October 9-13, 2018

Speaker Name: Caroline Colvin, PT, DPT, PCS and Molly Thomas, PT, DPT, PCS

Disclosure of Relevant Financial RelationshipsWe have no financial relationships to disclose.

Disclosure of Off-Label and/or investigative uses:We will not discuss off label use and/or investigational use in

this presentation.

Why are we all here?

• Are SDRs performed at your institution?

• Are you using a standard protocol for post-SDR PT?

• How long do you follow patients who’ve undergone SDR?

• Is there consistency with patient selection?

• Is a PT providing input when patients are recommended

for SDR?

Why is this important?

Increase in SDRs, with no common PT protocol globally:

Dosing (frequency, intensity, timing, and type)

Assessments (pre-op and post-op)

Outcomes measures

Goal setting

Family and patient education

SDR at a glance

• Historical perspective

Palpation vs intra-operative monitoring

Multi-level (conus) vs single-level (cauda equina) laminectomy

• Goals of SDR:

permanent reduction of spasticity

improvements in motor function

prevent progression of orthopaedic impairments

What is evidenced-based practice?

Finding the Current Evidence

• Goal: to examine evidence related to PT intervention and assessment for individuals who have undergone a SDR.

• Key words: selective +/- dorsal +/- rhizotomy, cerebral palsy, diplegia, spasticity, physical therapy, rehabilitation, strengthening, cerebral palsy, spastic cerebral palsy, exercise

• Databases: PEDro, CINAHL, Medline/Ovid, Cochrane

• Years Searched: 2000-2018

Finding the Current Evidence, continued

Assessments: using the International

Classification of Functioning, Disability, and

Health (ICF) Model

• Body Structures and Function

– Modified Ashworth Scale (MAS)

– Range of motion

– Strength testing

– Selectivity assessment

– Pain

Assessments: using the ICF Model, continued

• Activity

– Gross Motor Function Measure (GMFM): 88, 66, no mention of

Item Sets

– Walk tests: 1 minute walk test

– Gait analysis: 3D or observational (Observational Gait Scale or

Edinburgh Visual Gait Score), Physiological Cost Index

– Peabody Fine Motor Scale (PDMS-2): but gross motor could be

considered

Assessments: using the ICF Model,

continued

• Participation

– Pediatric Evaluation of Disability Inventory (PEDI):

• Self-care and mobility domains

• Functional skills and caregiver’s assistance dimensions

– Canadian Occupational Performance Measure (COPM)

Current Practices

ICU/ IP stay IP Rehab OP therapies

5-7 days 1-6 weeks 9-24 months

Dosing/FITT

• Frequency:

– Pre-op intensive

– Up to 3-5 times per week initially and then tapered down to 1

time per week

• Intensity: not discussed

• Timing:

– Overwhelmingly supports initiation of PT within 1 week of SDR

– Variation between 9-24 months of direct PT following SDR

Dosing/FITT, continued

• Type:

– Strengthening

– Stretching

– Bed mobility

– Transfers

– Gait training

– Postural training

– Balance training

– Equipment and orthoses

Further Research Needs

• Dosing

• Assessment battery

• PT protocol

• Selection criteria

Good news…we are collaborating with Amy Schulz, DPT and Heather Forst, OTR/L at Gillette Children’s Specialty Healthcare on an APTA sponsored Clinical Practice Guideline for SDR care.

Questions

• Caroline Colvin: caroline.colvin@cchmc.org

• Molly Thomas: molly.Thomas@cchmc.org

References

• Al-Shaar H, Imtiaz M, Alhalabi H, Alsubaie S. Selective dorsal rhizotomy: a multidisciplinary approach to treating spastic diplegia. Asian Journal of Neurosurgery. 2017,12:454-465.

• Bolster E, van Schie P, Becher J, van Ouwerkerk, Strijers R, Vermeulen R. 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.

• Cawker S, Aquilina K. Selective dorsal rhizotomy (the perspective of the neurosurgeon and physiotherapist). Paediatrics and Child Health. 2016. 395-399.

• Dudley R, Parolin M, Gagnon B, Saluja R, Yap R, Montpetit K, et al. Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy. J Neurosurg: Pediatrics. 2013,12:142-150.

• Funk J, Panthen A, Bakir M, Gruschke F, Sarpong A, Wagner C, et al. Predictors for the benefit of selective dorsal rhizotomy. Research in Dev Disabilities. 2015,37:127-134.

• Grunt S, Fieggen A, Vermeulen R, Becher J, Langerak N. Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: as systematic review of the literature. Dev Med Child Neurol. 2014,56:302-312.

References

• Josenby A, Wagner P, Jarnlo G-B, Westbom L, Nordmark E. Motor function after selective dorsal rhizotomy: a 10 year practice-based follow-up study. Dev Med Child Neurol. 2012,54:429-435.

• Josenby A, Wagner P, Jarnlo G-B, Westbom L, Nordmark E. Functional performance in self-care and mobility after selective dorsal rhizotomy: a 10-year practice-based follow-up study. Dev Med Child Neurol. 2014,57: 286-293.

• McLaughlin J, Bjornson K, Temkin N, Steinbok P, Wright V, Reiner A, et al. Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol. 2002,44:17-25.

• Nicolini-Panisson R, Tedesco A, Folle M, Donadio M. Selective dorsal rhizotomy in cerebral palsy: selection criteria and postoperative physical therapy protocols. Rev Paul Pediatr. 2018;36(1)(:100-108.

• Nordmark E, Jarnlo G-B, Hagglund. Comparison of Gross Motor Function Measure and Paediatric Evaluation of Disability Inventory in assessing motor function in children undergoing selective dorsal rhizotomy. Dev Med Child Neurol. 2000,42:245-252.

• Nordmark E, Josenby A, Lagergren J, Andersson G, Stromblad L-G, Westbom L. Long-term outcomes five years after selective dorsal rhizotomy. BMC Pediatrics. 2008,54(b):1-15.

References

• Roberts A, Stewatr C, Freeman R. Gait analysis to guide a selective dorsal rhizotomy. Gait & Posture. 2015,42:16-22.

• Romei M, Oudenhoven L, van Schie E, van Ouwerkerk W, van der Krogt M, Buizer A. Evolution of gait in adolsecents and young adults with spastic diplegia after selective dorsal rhizotomy in childhood:a 10 year follow-up study. Gait & Posture. 2018,64:108-113.

• Steinbok P, McLeod K. Comparison of motor outcomes after selective dorsal rhizotomy with and without preoperative intensified physiotherapy in children with spastic diplegic cerebral palsy. 2002,36:142-147.

• Van Schien P, Vermeulen R, van Ouwerkerk W, Kwakkel G, Becher J. Selective dorsal rhizotomy in cerebral palsy to improve functional abilities: evaluation of criteria for selection. Child’s Nervous System. 2005,21:451-457.

• Vermeulen R, Becher J. Long-term outcome in selective dorsal rhizotomy in spastic cerebral palsy: differentiation in mobility levels is needed. Dev Med Child Neurol. 2015;57(5):408-409.