# Are Electromyography Data a Fingerprint for Patients with Cerebral Palsy (CP)?
## 4 Discussion
While prior studies addressed pre-treatment femoral anteversion [32], knee flexion [33], dynamic hip flexion [34], and gait profile score [35] as predictors of postoperative outcomes, this is the first study to examine the connection between DMC and gait following surgery in a relatively homogeneous group of patients with CP. Comparing the type and number of surgeries among the responders, it appears that those with poor pre-treatment gait quality who demonstrated better responses underwent the most extensive surgical interventions. Furthermore, proximal surgeries, such as rectus transfer, hamstring lengthening, and femoral derotation, seem to have resulted in higher responder rates compared to distal surgeries, such as Baumann-Strayer and bony foot procedures, for patients with initially poor and mild gait quality. However, in other responding groups, such as patients with good pre-treatment gait quality, distal surgeries are more prevalent than proximal ones. Although the variability in the type and number of surgeries introduces a potential source of bias in the grouping methodology used in this study, adjusting for this variable lies beyond the scope of this research. It is important to emphasize that treatment for patients with CP typically begins in early childhood and continues throughout their lifetime. Moreover, patients often undergo multiple corrective procedures targeting both soft tissue and bone deformities within a single orthopedic intervention, commonly referred to as single-event multi-level surgery (SEMLS). These surgeries are often performed by different surgeons at various stages of treatment, introducing additional variability to the therapeutic process. Consequently, when working with large datasets, it becomes clinically challenging to disentangle the effects of factors such as the type and number of treatments, the expertise of the surgeon or clinician, and other contextual variables. Our research primarily focused on the applicability of EMG as a clinical measure to enhance decision-making for patients with CP. However, we recommend that future researchers conduct more focused studies on the impact of different surgical approaches on EMG changes and their relationship with gait improvement. Additionally, the influence of growth, changes in muscle mass, and spasticity over time, particularly following surgery, on the EMG and gait of patients with cerebral palsy should also be explored in future studies. One of the factors that may influence the results is the patients' growth, including both changes in body mass and height. While it is well-established that the gait patterns of typically developing children over the age of 8 closely resemble those of adults [36], this relationship is not sufficiently confirmed in children with CP, especially in longitudinal studies. The ability of the neuromuscular system in children with CP to adapt to growth and anatomical changes remains unclear. For example, increases in body weight in the presence of structural abnormalities may necessitate changes in muscle activation, such as recruitment or inhibition of muscles that typically do not alter their activation patterns with maturation. Additionally, spasticity levels, which can vary significantly across the cohort, may also have a significant impact on muscle activation patterns and gait. These factors, particularly the effects of aging, spasticity, and growth, could introduce variability in the data, and while we have noted their potential influence, they were not the primary focus of this study. This limitation may warrant further exploration in future research to better understand their role in surgical outcomes for children with CP. From a clinical perspective, this study highlights the importance of integrating DMC and EMG indices into pre-surgical evaluations to enhance the prediction of surgical outcomes in patients with CP.