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physical therapists guide patients through a series of tests using advanced technology. During a walking test, for example, infrared cameras are used to capture pictures of the skeleton — particularly the relationship of the joints to one another. Therapists also administer plantar pressure testing to col- lect information that can be analyzed for a better understanding of gait patterns and the distribution of pressure under the feet. Gait analysis also includes a thorough physical exam as well as an electromyogram. Data derived from these studies is used to inform decision-making about treatments and, specifically, whether or not a child is an appropriate candidate for selective dorsal rhizotomy. "Once all of the data is collected, a certified gait interpreter will meet with the thera- pist and an engineer from the gait lab to go through the data and video and learn about patients and their history," says Michael Healy, MD, pediatric orthopedic surgeon at Gillette. "From there, we do an interpretation and begin to form opinions around what the best course of treatment is going to be." "Some of the things we look for following the gait analysis include muscle overactivity and high-energy oxygen consumption that is at least two times the normal expendi- ture for a similarly aged peer," adds Tom Novacheck, MD, Director of the James R. Gage Center for Gait and Motion Analysis and pediatric orthopedic surgeon at Gillette. "In terms of movement, we also look for muscle sti™ness in the knee during stance and swing, as well as excessive plantar fasciitis during stance and swing." A MEETING OF THE MINDS Following the gait analysis, families come to the Spasticity Evaluation Clinic for an assessment. Like in the Motor Delay Diagnosis a nd Treatment Clinic, this multidisciplinary clinic gives families an opportunity to meet all of the physicians who may be involved in their child's care at the same appointment. The providers involved in spasticity evaluation and treatment include pediatric rehabilitation medicine special- ists, pediatric neurosurgeons and pediatric orthopedic surgeons. As part of the evaluation, children may have MRI or CT scans, which enable neuro- surgeons to look at the brain or spinal cord pathology contributing to spasticity. The pediatric rehabilitation medicine specialists also evaluate how spasticity impacts a child's function, while the orthopedic surgery team analyzes how spasticity a™ects the child's skeletal development. " The multidisciplina r y clinic g ives parents a comprehensive view of what lies ahead," Dr. Healy says. "We educate parents about rhizotomy and the four-to-six weeks of rehabilitation that follows. We also speak with parents about the orthopedic concerns causing diƒcult ambulation. Most of the children who are selected for rhizotomy are ambulatory, so we discuss any improvements in skeletal alignment that can be made after tone reduction to correct dysfunction. This comprehensive discussion gives families a realistic idea of what's expected and allows us to better work with them on shared goal-setting." Available treatment modalities in addi- tion to selective dorsal rhizotomy include physical therapy, onabotulinumtoxinA and phenol injections, medication, and the use of casting or orthotics. Children that have widespread high muscle tone in their arms and legs may also be candidates for place- ment of an intrathecal baclofen pump. This device delivers doses of baclofen directly into the intrathecal space, which allows physicians to lower the dose needed to reduce muscle tone and lessen the risk of systemic side e™ects. A STATE-OF-THE-ART PROCEDURE Selective dorsal rhizotomy is a complicated three- to four-hour surgery during which neurosurgeons identify and cut the sensory nerve roots contributing to the abnormal signals responsible for spasticity. "Rhizotomy entails unroofing bones from the back of the lower spine and isolating the nerve roots that carry information that may be a™ecting spasticity," says Debbie Song, MD, pediatric neurosurgeon at Gillette. "On both the right and left side, we tease each of the dorsal roots into tiny rootlets and intraoperatively use electronic impulses to simulate the rootlets. The phys- iatry team helps us monitor the signals, and we cut the rootlets carrying the abnormal messages that contribute to spasticity." After surger y, children complete an intensive, four- to si x-week inpatient rehabilitation program. This is followed by outpatient therapy that ta kes place five days a week for the first month or two after surgery. "Initially, we restrict walking so children can regain their strength and gross motor skills," says Angela Sinner, DO, pediatric rehabi litation medicine specia list at Gillette. "During inpatient rehabilitation, children spend time on their stomachs to build core strength and practice kneeling and sitting positions to strengthen under- developed muscles. Towards the end of the inpatient program, they perform supervised walking, and we work with children to adopt a heel-to-toe reciprocal gait pattern." One year after surgery, children have a postoperative gait analysis to evaluate the eƒcacy of the procedure. EXPLORING CANDIDACY FOR SELECTIVE DORSAL RHIZOTOMY Children who are candidates for selective dorsal rhizotomy are typically ambulatory and have spastic diplegia in which high muscle tone and sti™ness most commonly occur in the legs. In recent years, however, indications for rhizotomy have expanded to include certain children with spastic quadriplegia who are not candidates for Rehabilitation is an integral part of treatment plans. 0 8 0 8C O V E R F E A T U R E

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