Maximising impact of gait analysis reports on non-surgical management of children with neurodisability.

Purpose

Instrumented gait analysis (IGA) impacts clinical decision-making in orthopaedic management planning for ambulant children with neurodisability (CwND). Studies shown that IGA influences paediatric surgery planning, but clarity on paediatric physiotherapy practice impact is sparse. Physiotherapists play an important role in helping ambulant CwND fulfil functional potential through management of walking ability, gait improvement training, equipment and post-operative gait rehabilitation but possibly under-use IGA. The study aim was to improve utilisation of IGA reports in inter-disciplinary management of CwND.

Our team followed IGA recommendations in 89% of cases
which is high compared to the literature.

Approach

The inter-disciplinary gait analysis paediatric orthopaedic service at the Royal London Hospital was evaluated by retrospective review of 18 consecutive ambulant patients (12 male 6 female, aged 5-17 years) with a diagnosis of cerebral palsy (14), spina bifida (1) and other movement disorders (3) referred for IGA as part of management planning between 2015-2018. Referrals were made by 3 paediatric orthopaedic consultants and one specialist paediatric physiotherapist, then booked for review with the referrer after receipt of the IGA report

Analysis: Descriptive statistics (SPSS); the factors influencing gait-related shared decision-making recorded in medical charts were coded in accordance to International Classification of Functioning, Disability and Health ICF.

Outcomes

IGA reports and recommendations were discussed by the inter-disciplinary team including surgeons and specialist physiotherapist in 16 out of 18 cases, in 1 case physiotherapist was not present, in 1 case the report was discussed by the physiotherapist only. Recommendations to proceed with surgical interventions were made in 8 CwND (45%) and followed in 6 cases, in all of which the community physiotherapist was informed about the surgical plan and IGA results. For 10 (55%) CwND the recommendation was to postpone or avoid surgical intervention in favour of non-operative treatment. The recommendations were followed in all those cases, and consisted of exercise programmes, orthotics or walking equipment. In only 3 of these 10 cases were community physiotherapists informed of the IGA recommendations and report findings. No further support in translating report findings to develop specific therapy prescription were requested by community physiotherapists or given by our service.

Paediatric physiotherapists play an important role in the management of ambulant CwND. Our service reflected this in its multidisciplinary approach. Our team followed IGA recommendations in 89% of cases which is high compared to the literature. There was a high percentage of children where surgery was not recommended, and non-operative treatment advised. Multiple studies report that non-operative modalities are frequently recommended, but no information on the impact on decision-making is given. Despite the inter-disciplinary approach, IGA report findings were rarely shared with community teams, requiring service re-design to ensure information sharing becomes routine practice. When non-operative care is recommended the existing IGA reports should be utilised to support the exercise prescription accordingly.

Cost and savings

This project was part of the gait analysis service evaluation review and development planning. Project did not produce any additional cost to date.

Sharing IGA results may optimise non-operative treatment planning without the economic barrier, and maximise the cost effectiveness of the future referrals.

Implications

Robust pathway for review and information sharing is underway, with a stakeholder group involvement planned for early next year.

Outreach and networking – building a community of practice with strong links with the gait laboratory and orthopaedic centre and community teams.

Education and support – supporting colleagues with less exposure to gait analysis in transferring the findings of the report into practice; currently this support occurs on one-to-one basis, but an educational intervention is underway to address the needs locally.

Impact on the future projects:

  • The impact of IGA data on non-surgical treatment planning should be investigated further.
  • The potential to positively impact on patient outcomes when non-surgical treatments are decided should not be ignored and is worth a further investigation.

Top three learning points

  1. Gait analysis recommends less surgery when compared to initial clinical plans in management of children and young people with neurodisability.
  2. Agreement between recommendations and treatment performed were at the higher reported levels at our centre in comparison to literature (especially considering the absence of direct affiliation with gait team).
  3. The gait analysis results should be routinely shared with community teams to inform the conservative treatment and to maximise IGA referral cost-effectiveness.

Fund acknowledgements

No funding has been received for completion of this study. 

Additional notes

This work was presented at Physiotherapy UK 2019

 

For further information about this work please contact Anna Hebda-Boon