Observational Gait Scale – Update (3/2/2017)
(I reviewed the original OGS post and the data is still up to date)
Dursun N, Gokbel T, Akarsu M, Dursun E. A Randomized Controlled Trial on Effectiveness of Intermittent Serial Casting on Spastic Equinus Foot in Children with Cerebral Palsy After Botulinum Toxin-A Treatment. Am J Phys Med Rehabil. 2016;
Purpose: To explore the efficacy of a combined treatment approach of intermittent, progressive serial casting and physical therapy (PT) after botulinum toxin-A (BTX-A) injections on spasticity, passive range of motion (PROM), and gait of children with CP.
Study Population: 54 patients between ages 3 and 17 with diagnosis of CP according to Rosembaum criteria, hemiplegic or diplegic type of involvement, a Gross Motor Functional Classification System level of I, II, or III, presence of unilateral or bilateral spastic equinus foot deformity with shortened plantar flexors, a Modified Ashworth Scale (MAS) score of 3 in plantar flexor muscles, and a scheduled BTX-A injection treatment for spastic plantar flexors.
Methods & Interventions: Patients were randomly assigned to either a casting group or control group (in a ratio of 2:1). BTX-A injections were administered to target muscle groups of all patients under guidance of electrical stimulation and in an individualized manner. All patients received injections to plantar flexors, but several patients from both groups received multilevel injections. Both groups participated in a PT program with 1-hour sessions, 5 days per week, for 3 weeks. The PT program focused on stretching, strengthening, weight bearing, balance, proprioception, and ambulation activities and exercises. The casting group received a series of progressive casting on top of the PT. Ankle joint positioning was progressed based on improvements made in passive dorsiflexion. All patients were followed for 12 weeks and data was collected along the way regarding any changes in muscle tone and spasticity, PROM, gait function, or if there was an adverse event. Primary outcome measures included PROM and MAS, and secondary outcome measures included the Tardieu, Observational Gait Scale (OGS), and Physician Global Assessment (PGA). Comparison of baseline, week 4, and week 12 within-group evaluations of PROM, spasticity measurements, OGS, and PGA were performed using Friedman test. The Mann-Whitney U test was applied and used for all comparisons between independent group medians.
Outcome Measures: Muscle tone and spasticity were assessed and measured using the MAS and Tardieu scales. All patients were videotaped to evaluate gait during each visit per the OGS protocol. A physician blinded to the treatment protocol performed the MAS, Tardieu, and OGS assessments for all patients.
Results: There were 3 drop-outs along the way, bringing the total number of participants down to 51. There were no statistically significant differences found between the casting and control groups regarding type of involvement, Gross Motor Functional Classification System levels, age, and sex (P > 0.05 for all parameters). There were no statistically significant differences found between the casting and control groups related to baseline spasticity data (P > 0.05 for all parameters). Both groups showed statistically significant improvements in angle of catch at fast speed and spasticity angle (both components of Tardieu Scale), MAS and PROM (P < 0.001 for all parameters of both groups). A statistically significant decrease in spasticity grade (component of Tardieu Scale) was also found in the casting group (P < 0.001). Statistically significant improvements for all parameters (P < 0.05) were determined to have been reached by week 4 and maintained at week 12 using post hoc data analysis. Between group analysis revealed that average changes in PROM, MAS, angle of catch at fast speed, and spasticity angle measures were significantly higher in the casting group compared to the control group. There were statistically significant improvements in OGS scores for both groups.
Strengths/Limitations: The interventions used seemed to be strong components of the study as both groups showed improvements in almost all outcome measures. That being said, there was little information regarding what specific PT interventions were used and whether PT varied based on age or not. The study also had a fairly wide age range, which could have potential implications regarding the applicability of the data to a particular age group. On the flip side, having a wide age range could be considered a strength in terms of the generalizability of the data.
Conclusion: The study showed that certain populations of children with specific types of CP may indeed benefit from a progressive, intermittent serial casting intervention when combined with PT (after having received BTX-A injections) as shown by statistically significant improvements in various outcome measures related to muscle tone and spasticity, gait function, joint mobility, and PROM in affected spastic muscles.
2 responses to “Observational Gait Scale – Update (3/2/2017)”
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I’ve always found serial casting to be fascinating for muscle contractures. I’m glad to see that study showed that both PT interventions and serial casting can increase function in this domain, as it is good to see that patients with spastic equinus feet have options. Having options for these patients gives them more autonomy and likely leads to overall better results.
I completely agree Garrett. The more options we can give our patients, the greater our ability to collaborate with them and help determine the most appropriate and effective intervention to give them the best possible outcome.