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Management of Children With Ambulatory Cerebral Palsy: An Evidence-based Review

Narayanan, Unni G. MBBS, MSc, FRCS(C)*,†

Journal of Pediatric Orthopaedics: September 2012 - Volume 32 - Issue - p S172–S181
doi: 10.1097/BPO.0b013e31825eb2a6
EBM Supplement

This article reviews the current best evidence for musculoskeletal interventions in children with ambulatory cerebral palsy (CP). The effectiveness of interventions in CP must first consider what CP and its associated pathophysiology are and take into account the heterogeneity and natural history of CP to put definitions of “effectiveness” into perspective. This article reviews the current standards of the definition and classification of CP, discusses the natural history and specific goals for the management of ambulatory CP, as well as the outcome measures available to measure these goals. The current best evidence of effectiveness is reviewed for specific interventions in children with ambulatory CP including spasticity management with botulinum toxin A injections and selective dorsal rhizotomy; multilevel orthopaedic surgery to address contractures and bony deformity; and the role of gait analysis for surgical decision-making before orthopaedic surgery.

*Divisions of Orthopaedic Surgery & Child Health Evaluative Sciences, The Hospital for Sick Children

Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada

The author has not received financial support for this manuscript.

The author declares no conflict of interest.

Reprints: Unni G. Narayanan, MBBS, MSc, FRCS(C), The Hospital for Sick Children, 555 University Avenue, S-107, Toronto, ON, Canada M5G 1x8. E-mail:

Cerebral Palsy (CP) is the most common cause of chronic physical disability in children affecting between 2 and 3 per 1000 children.1 The impact is lifelong and affects not only the child with CP, but also their parents and caregivers, the family, the health care system, and potentially society at large. In the absence of a cure, children with CP are subjected to numerous interventions to address the secondary consequences of the primary neurological pathology. This article reviews the current best evidence for the (musculoskeletal) interventions for children with ambulatory CP, with much of the content derived and updated from 2 systematic reviews on the subject.2,3

Any discussion about the effectiveness of interventions in CP must first consider what CP and its associated pathophysiology are and take into account the heterogeneity and natural history of CP in order to put definitions of “effectiveness” into perspective. This article will review the current standards of the definition and classification of CP and discuss the functional trajectory associated with the natural history, before outlining the specific goals for the management of ambulatory CP, as well as the list of validated outcome measures available to measure whether these goals are achieved. This background is essential to contextualize the current best evidence about the effectiveness of various musculoskeletal interventions to achieve these goals for children with ambulatory CP.

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The term CP refers to a heterogeneous group of disorders of the development of movement and posture that are permanent and attributable to nonprogressive disturbances that occurred in the developing fetal or infant brain.4 The primary disorder in the brain is associated with abnormal muscle tone, most often hypertonia, accompanied by loss of selective motor control, muscle weakness, and impaired balance.5 The motor disorders contribute to secondary musculoskeletal problems including muscle contractures, bony deformities, and joint instability. Normal muscle growth occurs in response to the stimulus of stretch derived from typical physical activities associated with normal motor development. Hypertonia and the limited use of muscles due to developmental delay result in dynamic contractures, which become static joint contractures over time as the tight muscles fail to grow in proportion to the long bones which they traverse.6 The growing skeleton remodels in response to typical stresses associated with the motor milestones, which when delayed, or absent, result in retention of infantile morphology and development of secondary bony deformities and joint instability, which contribute to lever-arm dysfunction.7 The interaction of joint contractures, muscle weakness, bony deformities, and joint instability at multiple levels affect the quality and efficiency of gait and other aspects of physical function in children who are ambulant or deformities of the trunk and limbs in those who are nonambulant.

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Children with CP have wide variability in presentation and severity. Conventionally, CP has been classified by the predominant type of movement disorder (eg, spastic, dystonic, choreoathetoid, mixed, ataxic, etc.) and topographic involvement (hemiplegia, diplegia, and quadriplegia). Although these systems continue to have some clinical utility, they have not shown to be very reliable or predictably prognostic. The GMFCS is a 5-level ordinal rating system, which has become the international standard for categorizing individuals based on the severity of their motor disability.8 The GMFCS has been shown to be reliable and valid,9 and its prognostic utility has been established in a prospective longitudinal population-based cohort study.10 Children in GMFCS level I can perform all the activities of their age-matched peers, albeit with some difficulties with their speed, balance, and coordination. Level II children have similar functional abilities on flat and familiar surfaces but require support when negotiating uneven surfaces or stairs. Children in level III are also independent walkers but require an assist device such as a cane, crutches, or a walker and may use wheelchairs for longer distances. Children in levels IV and V are nonambulatory. In level IV, they may weight bear for transfers and use a walker for exercise purposes, whereas level V children do not achieve any functional weight bearing and are usually totally dependent on caregivers. The GMFCS provides an excellent basis for stratification of patients and should be used to classify patients in any clinical trial or outcome study.

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It is well established from prospective longitudinal studies that gross motor function improves in all children with CP up to the age of 6 or 7 years, reaching a different plateau of function for each GMFCS level, which then remains stable after motor development is complete at least until early adolescence.10 Any observed improvements in function after an intervention in a younger child must therefore be placed in the context of expected improvements in gross motor function before the age of 7 years. In contrast, the secondary musculoskeletal pathology tends to worsen with growth so that many ambulant children with CP experience deterioration of gait over time, especially during adolescence11–13 (Fig. 1). Consequently, in older children, the effectiveness of any interventions must be interpreted in the context of natural deterioration of gait with growth. Uncontrolled case series will be likely to overestimate the effectiveness of interventions in younger children and underestimate the effectiveness in older children.14 Furthermore, short-term outcomes are less meaningful, because the growing child is at risk for recurrent deformity and gradual loss of mobility over the long term. These issues have implications both on the optimal age at which the surgical interventions should be performed and the timing of outcome assessments.



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The primary goal of treatment of ambulant children with CP (GMFCS I to III) is to improve or optimize their gait, with the expectation that this will preserve or improve their physical function and provide them with the ability to increase their participation in physical activities, recreation, and sport. What does “improving gait” actually mean? It includes improving speed and endurance, optimizing balance and stability, preventing tripping and falls and reducing reliance on walking aids, reducing fatigue, and eliminating or preventing pain. Another important goal for many children, and most parents, is to improve the appearance of gait.15

The International Classification of Functioning, Disability and Health (ICF) model, developed by the World Health Organization (WHO), provides a framework in which human functioning and disability are described as a dynamic interaction between various health conditions and environmental and personal factors (Fig. 2). It provides a unified, standard language that describes how people with a health condition function in their daily lives and is the recommended model to analyze and categorize treatment outcomes.16,17 A common assumption is that treatment directed at 1 level in the ICF framework, such as “body structure and function” (eg, knee flexion contracture or crouch gait) may positively affect another level such as “activity and participation” (eg, by permitting independent walking over longer distances). Similarly, interventions do not always have simple effects on a single dimension. For example, powered mobility may increase activities by providing an alternative means of efficient locomotion, which may also increase participation by allowing a student to be independent and move around the school faster and with less effort but may have negative effects at the level of body structure and function such as increased knee flexion contractures.18 It is essential, therefore, to develop explicit goals for our interventions and to ensure that these goals are in line with the priorities of the children receiving these interventions or those of their parents. Evaluating the effectiveness of interventions to achieve these goals requires defining the outcomes of interest at multiple levels and defining the longevity of these outcomes.19,20 There are a number of outcome measures currently used for children with ambulatory CP:



  1. Gait Analysis and Gait Analysis-derived Gait Indices: In addition to the temporospatial measures of gait velocity, stride length, and cadence, there are a number of summary statistic measures derived from 3-dimensional (3-D) gait analysis that attempt to quantify the magnitude of the deviation of a child’s gait from normal. The Gillette Gait (Normalcy) Index (GGI) is a single dimensionless measure that serves as a proxy for the overall gait pattern based on kinematic data and has been shown to be reliable, discriminative, and sensitive to change after orthopaedic interventions for CP.21,22 The Gait Deviation Index is a conceptually similar but is reportedly a superior multivariate measure of overall gait pathology also derived from the kinematic data.23 The Gait Profile Score (GPS) is yet another single-index measure that summarizes the overall deviation of kinematic gait data relative to normative data.24 The GPS can be decomposed to provide Gait Variable Scores of 9 key component kinematic gait variables, which are presented as the Movement Analysis Profile.25 These are measures of impairment at the ICF level of body function and structure, which do not necessarily correlate with the components of function at the level of activities and participation26 but may be good summary measures of the overall appearance of gait. The following are better measures of function at the level of activities and participation.
  2. Gross Motor Function Measure (GMFM-66) is a well-validated, condition-specific measure of gross motor function in children with CP.27–29 The GMFM has been used extensively in numerous intervention trials and has been shown to be sensitive to change after muscle/tendon surgery in ambulatory children with CP.30 The GMFM is a measure of capability (observed under ideal circumstances) rather than actual performance.
  3. The Pediatric Outcomes Data Collection Instrument was developed and validated to serve as a measure of musculoskeletal functional health outcomes in children and adolescents. The measure includes scales assessing upper extremity function, transfers and mobility, physical function and sports, comfort (pain), happiness and satisfaction, and expectations of treatment.31 It is reliable and valid for use in children with CP32 but has been shown to have only modest sensitivity to change after orthopaedic surgery in these children.30
  4. The Gillette Functional Assessment Questionnaire is a reliable, condition-specific functional scale developed for children with CP,33 which comprises a 10-level parent report of walking abilities and an assessment of the degree of difficulty of accomplishing 22 higher-skill levels. It has been used to evaluate effectiveness of orthopaedic surgery in ambulatory children with CP.34,35
  5. The Functional Mobility Scale was developed to measure functional mobility of a child in 3 different environments (home, school, and the wider community).36 It takes into account different assistive devices a child usually uses in the different environment settings and therefore provides more information about the child’s mobility. It has the advantage of measuring actual performance rather than capability, assessing what a child “does do” in everyday life rather than what a child “can do” in an idealized situation.

In summary, although there are several outcome measures that have been applied to children with ambulatory CP, each of these has some shortcomings. Some of these measures focus narrowly on the physical impairments rather than functional consequences; some assess capacity or capability rather than actual performance of functional activities; others are generic and include items that might not be relevant or are missing items that might be important. When we talk about improving or preserving “gait,” it is not always clear whether we mean the function of walking efficiently or the pattern of walking (appearance) or both. None of the measures explicitly incorporate the goals or expectations of ambulant children with CP or their parents in the assessment of the outcomes. These limitations are important to recognize in making judgments about the effectiveness of various interventions.

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A number of complementary strategies are used sequentially or in combination including physical therapy, orthotics (braces), and serial casting to simulate the stretch that would normally be derived from usual physical activity, to stimulate muscle growth. These are often accompanied by measures to reduce muscle tone by pharmacologic [botulinum toxin-A (BTX-A), phenol] or neurosurgical methods [selective dorsal rhizotomy (SDR), intrathecal baclofen]. These are believed to facilitate the stretch from therapy and serial casting and improve tolerance of brace wear, which in turn might prevent or delay the onset of static contractures and bony deformities.37,38 The musculoskeletal changes, collectively referred to as “lever-arm disease,” are best addressed with orthopaedic surgery.7

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Although a systematic review in the Cochrane Database in 2000 did not find sufficient evidence to support or refute the use of BTX-A in the treatment of lower limb spasticity in children with CP,39 subsequent systematic reviews of more recent randomized trials confirm that injection of BTX-A compared with placebo40–43 does reduce calf (equinus) spasticity and increase ankle dorsiflexion and improve gait pattern in the short term.44,45

When compared with serial casting alone, BTX-A injections have been shown to be as efficacious in the management of dynamic equinus in 2 small randomized clinical trials (RCTs).46,47 The BTX-A group had a more sustained response than casting, although median time to reintervention was similar in both groups.46 In a subsequent small RCT, patients were randomized to receive either serial casting alone or serial casting with BTX-A, which showed equivalent reduction in spasticity and increased dorsiflexion at 3 months in both groups but more sustained benefits in the cast-alone group at 12 months.48 In another small double-blind RCT, patients were randomized to receive BTX-A alone, placebo injection+casting, or BTX-A+casting. The 2 groups that were casted with placebo injection or BTX-A showed significant but equivalent improvements in spasticity reduction and passive range of motion and ankle kinematics at 12 months, whereas the BTX-A injection group (without casting) did not show any significant change.49 In a multicenterd clinical trial in the Netherlands, 46 children were randomized to receive multilevel BTX-A followed by comprehensive rehabilitation or just usual physical therapy. The BTX-A+comprehensive rehabilitation group experienced significantly greater improvements in the GMFM at 24 weeks [3.5 points better than usual physiotherapy (PT) group]. This effect, although clinically significant, is modest at best, and this study cannot separate the relative contributions of BTX-A from those of the cointervention of comprehensive rehabilitation to the improved outcome.50

A retrospective cohort study of 424 patients concluded that a program of serial multilevel BTX-A injections might delay the need for and reduce the frequency of orthopaedic surgery.51 However, this evidence is undermined by the unknown comparability of the treatment cohorts at baseline, the different time periods that the cohorts were treated, and the possibility of bias by indication.

In summary, BTX-A injections are superior to placebo injections in reducing calf muscle spasticity and increasing ankle dorsiflexion in the short term but only equivalent in efficacy in the short term when compared with serial casting, with mixed evidence regarding the combination of serial casting+BTX-A. There is limited evidence in the literature to support the widely held belief that the reduction in spasticity brought on by BTX-A potentiates the effect of physical therapy interventions to reduce the mechanical aspects of the hypertonicity37 and even less evidence that these effects translate into measurable functional benefits in terms of activities and participation. Furthermore, the long-term effects or benefits of BTX-A in terms of improved muscle growth, mobility, and function remain unknown.52

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Three randomized trials have evaluated the efficacy of SDR followed by SDR+PT compared with PT alone.53–55 All 3 trials showed that SDR+PT consistently reduced spasticity, but only in 2 of the smaller trials, there was a significantly greater improvement in function (as measured by the GMFM) in the SDR+PT groups at 1 year. In the largest of the 3 trials (n=38), there was no demonstrable difference in functional outcomes (GMFM) between the 2 groups either at 12 or 24 months, with both groups demonstrating equivalent functional gains. A meta-analysis of these 3 trials confirmed that for children between 4 and 8 years of age with spastic CP, SDR+PT does produce a clinically significant reduction in spasticity at 12 months and a statistically significant but relatively small functional advantage of 4 points on the GMFM when compared with PT alone.56 In the multivariate analysis, a positive association was found between the percentage of rootlets transected and the magnitude of functional improvement. Despite the effectiveness of SDR in the short term, the question remains whether these small benefits are sufficiently compelling or cost effective. There is only limited evidence that SDR reduces the need for or amount of subsequent orthopaedic surgery,57–59 and the long-term effects and benefits of SDR have yet to be elucidated.

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Evidence for Multilevel Orthopaedic Surgery

Established or progressive musculoskeletal pathology is best addressed with orthopaedic surgery including musculotendinous lengthening or transfers and corrective osteotomies and joint stabilization procedures. Although single-level or selective combinations of procedures have been used in children with CP for many decades, there is general agreement that addressing all deformities simultaneously avoids the “birthday syndrome” of staged isolated procedures15 and limits the interventions to 1 hospitalization and 1 period of rehabilitation, based on small uncontrolled case series60,61 and expert opinion. However, to date, there are no comparative studies that have tested the superiority of this approach, called “single-event multilevel surgery” (SEMLS). Some surgeons recommend early surgical interventions during childhood development with the expectation that this will enhance function and allow further improvement of motor skills, with further surgery as needed when the child is older.62 This approach also uses multilevel procedures as needed and has been referred to as “Staged Multilevel Interventions in the Lower Extremity.” Apparent functional gains after early interventions must be considered in the context of the natural history of increasing function expected in all children with CP until the age of 6 or 7 years and in the absence of studies with controls, attributing that any functional gains to early surgery might be erroneous. There is some evidence from small case series that children with spastic diplegia who underwent staged orthopaedic procedures had unpredictable results.63 In contrast, there is little evidence that the preferred approach of SEMLS performed at the optimal (older) age eliminates the need for additional surgery in the future.

A recently published systematic review reported the findings of 31 studies of SEMLS, the majority of which were uncontrolled case series, with significant limitations: of study design or sample sizes, inadequate description and classification of their participants, insufficient details of the surgical procedures and other cointerventions, and outcomes reported in the short term.3 Most studies failed to categorize patients by (and therefore adjust for) severity or age or type of CP or take into account the effect cointerventions that are inevitable in multilevel surgery and are likely to have an impact on the outcomes.

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Outcomes of Multilevel Orthopaedic Surgery Compared With Natural History

There are 2 relatively small comparative studies that have evaluated the outcomes of SEMLS relative to the natural history. The first is a retrospective cohort study that compared the short-term outcomes in a small group of ambulatory children with spastic diplegia treated with multilevel surgery (n=12) with those of a control group of comparable children (n=12) who were recommended but did not undergo similar types of multilevel surgery.14 Effects of treatment were derived from change in gait analyses between the baseline assessment and 12 months later. Gait of children in the control group deteriorated between analyses, whereas parents of children in the treatment group perceived that their children’s walking distance and reliance on assist devices improved. Whether these benefits were a consequence of the multilevel surgery or the intensive postoperative PT (or both) that the operated patients received is not clear from this study and whether these benefits will last over the long term remains a concern in light of some evidence from longitudinal case series that mobility tends to deteriorate in growing children even after surgery.12,13

The second is a recently published pilot randomized trial that compared 11 children with spastic diplegia who underwent SEMLS with a control group of 8 children who were randomized to a program of progressive resistance strength training.64 At 12 months, the SEMLS group demonstrated a substantial improvement in gait as measured by the GPS and the GGI, whereas the control group did not change from their baseline. From the standpoint of functional outcome measures, however, the differences between the 2 groups was neither clinically nor statistically different at 12 months. The SEMLS group was followed prospectively up to 24 months by which time significant functional differences (5 points) compared with baseline were detectable as measured by the GMFM, a functional gain superior to those (in other studies) associated with botulinum toxin injections or SDR. The control group could no longer serve as a comparison group, as these patients were offered SEMLS at their 12-month follow-up.

There are few published studies that evaluated the long-term effects of multilevel orthopaedic surgery at skeletal maturity let alone into adulthood.20 Five-year results of the SEMLS trial are forthcoming and suggest that gait and gross motor improvements decline slightly but remain superior to those at baseline (Oral Communication).

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Outcomes of Multilevel Orthopaedic Surgery Compared With Other Interventions

In a prospective nonrandomized cohort study of ambulant children with spastic diplegia who underwent either SDR or multilevel orthopaedic surgery as their initial surgical procedure, children who underwent SDR (n=16) demonstrated improvements in the 3 of 5 dimensions and the total score of the GMFM, but over 60% of these patients experienced a reduction in gait velocity. Those who underwent orthopaedic surgery (n=14) had more predictable improvements in spatiotemporal gait parameters, although their improvements in the GMFM was limited to only 1 dimension (walking, running, and jumping) and the total score.65 In another prospective cohort study of children with spastic diplegia with a mean age of 73 months, 18 children who underwent SDR were compared with 7 who underwent orthopaedic surgery. Significant improvements were seen in passive range of motion, muscle tone, gait kinematics, and oxygen cost in both groups 2 years after surgery.59 In both these studies, the unknown comparability of the groups at baseline and the different indications for choosing SDR or orthopaedic surgery make any meaningful inferences futile. Furthermore, the 2 interventions should be seen as complementary, as they address different facets of the problem (spasticity in the case of SDR and fixed contractures and/or bony deformities in the case of multilevel orthopaedic surgery), rather than as competing alternatives to manage the ambulant child with spastic CP.

In summary, the overall quality of evidence in support of multilevel orthopaedic surgery for ambulatory children with CP is weak and based almost primarily on uncontrolled case series looking at prepost intervention comparisons and very few comparative studies. These studies demonstrate improvements in the short term in outcomes at the level of body structures and functions, such as range of motion, spatiotemporal gait parameters, and selected kinematic or kinetic improvements on gait analysis.20,66–70 Although there are significant improvements in gait quality as measured by summary gait indices, such as the GGI, there are only a few studies reporting benefits in some functional outcomes at the level of activities and participation.22,30,67,71 There is a trend to improvements in the Functional Assessment Questionnaire but relatively modest changes for other measures including the GMFM. These seemingly modest improvements might indeed be very important in older children who might otherwise be expected to experience a natural decline in their gait function. The lack of evidence should not be interpreted as evidence of ineffectiveness but should provide the impetus for larger, prospective multicentered longitudinal controlled studies to generate higher-quality evidence of effectiveness in these higher order domains.

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Although computerized 3-D gait analysis has unquestionably defined and continually refined our understanding of gait in general and pathologic gait in CP in particular, the use of gait analysis to guide clinical (surgical) decision-making before multilevel orthopaedic surgery remains an area of controversy among pediatric orthopaedic surgeons.72–74 There is good evidence that gait analysis does alter surgical decision-making at least some of the time.75–78 However, there remain concerns about the reliability (reproducibility) of these decisions or whether implementing these recommendations would result in different, let alone better outcomes. There is little consensus about the indications or choice of which procedures to perform during multilevel surgery.79,80 When the same gait analysis data were examined by gait analysis experts from 6 different institutions, there was only slight to moderate agreement in the list of problems generated by the experts.81 Agreement about specific surgical recommendations was similarly poor. Although gait analysis data are themselves objective, there is subjectivity in interpretation even among experts, with diagnoses and treatment recommendations varying significantly by surgeon or institution.81 In another study, there was variability in the kinematic data generated in 4 different motion laboratories that tested the same 11 patients.82 Although the clinical significance of some of this variability has been challenged,83 the treatment recommendations generated from these data were different across the 4 centers for 9 of the 11 patients. Variability arising from lack of standardization are being addressed in collaborative efforts such as the one reported by Gorton et al84 that was implemented across the 12 gait laboratories in the Shriner’s system in North America. These are technical problems, which will be solved with technical solutions. The issue of variability of interpretation and treatment recommendations remains to be addressed.73

Variability in the interpretation of gait data reflects the prevailing uncertainty (or controversies) about the causes and/or significance of specific findings and will only be resolved with ongoing clinical research and experience using gait analysis.85 Similarly, variability in treatment recommendations based on the same gait data also reflects differences of opinion about best strategies to deal with specific problems, which in turn can only be definitively resolved with comparative clinical trials or observational studies. There is an imperative for 3-D gait analysis before and after SEMLS in order to generate the evidence to establish the optimal surgical strategies for specific gait pathologies identified. Neither the variability in interpretation nor the variability in surgical recommendations is the fault of gait analysis per se, but as long as such significant variability exists, the recommendation that gait analysis is essential for all preoperative decision-making before multilevel orthopaedic surgery in clinical (as opposed to research) practice is currently not supported by the literature.73 A systematic review of the literature on the use of gait analysis in children with walking disorders reported that there was little published evidence that outcomes of surgery based on gait analysis are any better than outcomes of surgery based on observational analysis alone.86 A multicenter randomized trial is currently underway to answer this question. Meanwhile, there is wide variation across North America in the rates of utilization of gait analysis for surgical decision-making in the management of children with ambulatory CP.87 It is not clear whether there is corresponding variation in functional outcomes of children receiving multilevel orthopaedic surgery in different centers in North America, and if so, whether these differences are attributable to the use of gait analysis or other factors, such as surgical skill and experience or the quality of the postoperative rehabilitation.

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A summary of the current best evidence for different interventions in ambulatory CP is provided in Table 1. There is a relatively low level of evidence on which to base our current practice of orthopaedic surgery for children with ambulatory CP. There is some evidence (and broad consensus among most experts) that single-event multilevel orthopaedic surgery benefits the gait of ambulatory children with CP in the short term, especially when compared with the natural history. There is less evidence that these changes translate into improvements in the dimensions of activities and participation or that these benefits are long-lasting, let alone permanent. In contrast, even modest improvements or preservation of function should be seen as important in the context of expected decline in function during adolescence, and SEMLS remains the current standard in the orthopaedic management of children with ambulatory CP. There is a growing recognition for the need to improve and expand the evidence base for the orthopaedic management of children with chronic developmental disabilities.2,3,85 Further studies are needed to define the long-term outcomes in these children to improve our understanding of the indications, optimal timing, and the effects of multilevel surgery for this population.14 Although RCTs are desirable, these are not immediately forthcoming due to the high cost, multiplicity of interventions, need for long-term outcomes, and problems of recruitment and retention associated with the large numbers of patients from multiple centers needed to participate, which make such trials difficult to conduct or completely impractical.88 Alternatives to RCTs are beginning to emerge including pragmatic or practical clinical trials89 and the use of large-scale prospective observational cohort studies90 and multivariate analyses to account for heterogeneity of patient populations. Even the quality of lower-level study designs can be greatly improved by following established guidelines for such in the design and implementation of such studies.91,92



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The author is very grateful for the input from Professor Kerr Graham, in the preparation of this manuscript. Much of the best evidence generated in the field is a result of the work of Professor Graham. Professor Graham does not agree with some of the conclusions of this evidence-based review (specifically with respect to the outcomes of orthopaedic surgery and the role of gait analysis) and has kindly agreed to provide an accompanying commentary to provide his invaluable perspective.

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cerebral palsy; ambulatory children; evidence-based medicine; treatment outcomes; effectiveness; orthopaedic surgery; multilevel surgery; gait analysis

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