Rehabilitation in cerebral palsy evaluation of physiotherapy intervention after multi-level orthopaedic surgery

Complex orthopaedic surgery is often indicated in the management of deformity in children with spastic diplegic cerebral palsy (CP) and a long rehabilitation programme is important for a successful outcome. However, the frequency and content of physiotherapy treatment following surgery varies between centres. This thesis aimed at providing a scientific basis for post-operative rehabilitation following multi-level surgery in children with CP. The effect of muscle weakness on function in patients with CP is recognised. However, the short and long-term impact of multi-level orthopaedic surgery on muscle strength is unclear. Strength changes would have implications for both surgical and conservative treatment planning. The objectives of this study were to establish a better understanding of the impact of surgery on muscle strength, gait and function, as well as the natural history of weakness in CP. Furthermore, the study aimed to clarify whether physiotherapy, focused on resistance strengthening techniques, was more effective than routine physiotherapy. The reliability of a protocol for measuring muscle strength in lower limb muscle groups in this population was firstly established. A pilot study of 10 children with a diagnosis of spastic diplegic CP and healthy counterparts demonstrated a reliable strength testing protocol. The main study of 20 diplegic children who underwent multi-level surgery showed that despite improvements in gait parameters, significant loss of strength in lower limb muscle groups and gross motor function persisted at six months. The value of intensive physiotherapy was assessed in a randomised controlled trial six months after surgery. Advantages of resistance training over active exercise were demonstrated. Assessment at one year showed that surgical patients preserved the post-physiotherapy strength and function gains but these did not reach the pre-operative values. Another group of 10 diplegic children who received routine physiotherapy but no surgical treatment for 12 months showed significant deterioration of their gait. The rate of deterioration demonstrated in conservatively treated diplegic patients and the degree of weakness caused by surgery, should inform parents and clinicians during decisions regarding surgery. Future research in multi-level surgery should include specific strength assessment protocols. The results from the randomised clinical trial showed that overall intensive strengthening regimes after multi-level surgery are beneficial. This finding would have significant implications on managing resources and designing appropriate rehabilitation programmes after multi-level orthopaedic surgery.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Diagnosing acute bone and joint infection in children: how does imaging alter the probability of infection?

Acute bone and joint infections in children are serious, and misdiagnosis can threaten limb and life. Most young children who present acutely with pain, limping, and/or loss of function have transient synovitis, which will resolve spontaneously within a few days. A minority will have a bone or joint infection. Clinicians are faced with a diagnostic challenge: children with transient synovitis can safely be sent home, but children with bone and joint infection require urgent treatment to avoid complications. Clinicians often respond to this challenge by using a series of rudimentary decision support tools, based on clinical, haematological, and biochemical parameters, to differentiate childhood osteoarticular infection from other diagnoses. However, these tools were developed without methodological expertise in diagnostic accuracy and do not consider the importance of imaging (ultrasound scan and MRI). There is wide variation in clinical practice with regard to the indications, choice, sequence, and timing of imaging. This variation is most likely due to the lack of evidence concerning the role of imaging in acute bone and joint infection in children. We describe the first steps of a large UK multicentre study, funded by the National Institute for Health Research, which seeks to integrate definitively the role of imaging into a decision support tool, developed with the assistance of individuals with expertise in the development of clinical prediction tools.</p