Functional outcome measures used in clinical settings for children with cerebral palsy having gait corrective surgery: scoping review

Cerebral palsy (CP) is one of the most frequent causes of motor disability in children. Although the definition of CP specifies that the brain lesion to the developing fetal or infant brain is not progressive, it is now well known that the secondary consequences to the musculoskeletal system in a growing child are progressive. The natural history of CP is often characterized by a gradual deterioration of mobility over a 5-year period from childhood to the start of the adolescent growth spurt. For this reason, maintaining or improving gait and gross motor function is a common primary goal for children with CP and orthopaedic gait corrective surgery has been considered standard of care to aid in achieving this goal. Three-dimensional gait analysis (3DGA) has been established as a criterion standard measure to inform surgical intervention and evaluate gait outcomes in children with CP requiring orthopaedic surgery for gait correction. Yet, the reality is that use of 3DGA is uncommon in clinical settings due to the cost involved and the equipment and expertise required. In the absence of 3DGA, observational gait assessment via non-instrumented methods is a viable alternative in informing and reassessing surgical intervention. However, evaluations of orthopaedic surgical interventions must go beyond just assessing the changes in body structure and function associated with gait. The introduction of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) encourages a multidimensional perspective of measuring and documenting health outcomes. This framework creates a shift in focus from just measuring gait-related outcomes (“impairment” of body function and structure), to also measuring “activity” (action or task execution), and “participation” (involvement in life situations) outcomes to allow for more meaningful assessment of the child’s function following gait corrective surgery. There is a long-held assumption that functional activity and participation will improve if gait impairments are treated. However, due to limited reporting of activity and participation measures to reflect surgical outcome, the correlation between gait impairment with activity and participation is poorly understood. Changes in gait may not necessarily translate into clinically significant or meaningful changes in activity and participation. Despite the large body of literature evaluating outcomes of gait corrective surgery for children with CP, there is lack of consensus regarding which non-instrumented measures of gait, activity and participation outcome measures are most suitable to be collected pre- and post-surgery. Therefore, the aim of this scoping review is to identify the most frequently reported non-instrumented measures of gait, activity and participation for children with CP undergoing gait corrective surgery. By doing so, we may be able to help direct further work towards developing a core set of outcome measures for use in routine clinical practice.