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Plachta S, Levine SB, Carlberg K, Cirrincione PM, Vitale M, Lenke LG, Roye BD, Selber PRP. Sagittal spinopelvic alignment in ambulatory persons with cerebral palsy. Spine Deform 2024; 12:1099-1106. [PMID: 38632183 DOI: 10.1007/s43390-024-00866-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 03/19/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE This study aimed to describe the spinopelvic alignment of a cohort of young ambulatory individuals with cerebral palsy (CP) and compare it to published spinopelvic alignment data for the typically developing adolescents. METHODS Thirty-seven adolescents (18 females) with CP at GMFCS I-III were included in this retrospective case series. Lumbar lordosis and pelvic incidence were measured, and their mismatch was calculated. A model that calculates predicted lumbar lordosis based on pelvic incidence in normative data was utilized to calculate a predicted lumbar lordosis in this cohort with cerebral palsy. RESULTS At imaging, ages were mean and standard deviation 13.5 ± 3.0 years. Pelvic incidence was 46.2° ± 12.9°, pelvic tilt was 2.8° ± 9.4°, sacral slope was 43.6° ± 10.8°, and measured lumbar lordosis was 59.4° ± 11.6°. There were no differences in pelvic incidence or lumbar lordosis among the GMFCS levels; however, pelvic incidence was higher in females. Pelvic incidence-lumbar lordosis mismatch greater than 10° was found in 67% of the cohort. Mean predicted lumbar lordosis based on the model was 54.7° ± 8.5°, averaging 8° less than measured lordosis. CONCLUSION PI-LL mismatch was identified in 67% of this cohort of ambulatory adolescents with CP, in part due to greater lordosis than predicted by a model based on data from adolescents without CP. The implications of this finding, such as the correlation between sagittal spinopelvic alignment and quality of life in this population, should be assessed further in ambulatory patients with cerebral palsy. LEVEL OF EVIDENCE Level IV-retrospective cohort study and literature comparison.
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Affiliation(s)
- Stephen Plachta
- Columbia University Irving Medical Center, 3959 Broadway, 8th Floor North, New York, NY, 10032, USA
| | - Sonya B Levine
- Columbia University Irving Medical Center, 1420 Locust St. #27Q, Philadelphia, PA, 19102, USA
| | - Kirsten Carlberg
- Columbia University Irving Medical Center, 3959 Broadway, 8th Floor North - 802A, New York, NY, 10032, USA
| | - Peter M Cirrincione
- University of Illinois College of Medicine Rockford, 1601 Parkview Ave, Rockford, IL, 61107, USA
| | - Michael Vitale
- Columbia University Irving Medical Center, 3959 Broadway, 8th Floor North - 802, New York, NY, 10032, USA
| | - Lawrence G Lenke
- Columbia University Irving Medical Center NewYork-Presbyterian Och Spine Hospital, New York, NY, 10032, USA
| | - Benjamin D Roye
- Columbia University Irving Medical Center, 3959 Broadway, 8th Floor North - 802, New York, NY, 10032, USA
| | - Paulo R P Selber
- Columbia University Irving Medical Center, New York, NY, 10032, USA.
- Hospital for Special Surgery, 535 East 70th Street, 5th Floor Room 5W-540, New York, NY, 10021, USA.
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Cirrincione PM, Nichols ET, Zucker CP, Chandran V, Zanini S, Jezequel J, Assip B, Backus SI, Doyle SM, Scher D, Selber P. Pelvic Tilt in Adults With Cerebral Palsy and Its Relationship With Prior Hamstrings Lengthening. Orthopedics 2024:1-6. [PMID: 38935848 DOI: 10.3928/01477447-20240619-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
BACKGROUND Current studies assessing the change in pelvic tilt for ambulatory patients with cerebral palsy (CP) after surgical hamstring lengthening (SHL) lack a comparison cohort without prior SHL and are limited to younger patients. This study presents gait data of middle-aged adults with CP, primarily focusing on the pelvis, and compares pelvic tilt, trunk tilt, and knee flexion between those with and without prior SHL. MATERIALS AND METHODS A consecutive series of 54 adults with CP, a mean age of 36±13 years, and Gross Motor Function Classification System (GMFCS) levels I-III were included. Thirty-two (59%) had SHL performed at a mean age of 8±5 years. Three-dimensional gait analysis data prospectively collected at a mean of 28±14 years postoperatively were retrospectively analyzed. Chi-square tests were used to compare demographic and surgical history data and statistical parameter mapping was used to compare knee flexion during stance and pelvic and trunk tilts during the gait cycle between SHL and SHL-naive groups. RESULTS Age, GMFCS level, sex, race, topography, and ethnicity were not different between the groups (P=.217-.612). Anterior pelvic tilt throughout gait was significantly greater in the SHL group compared with the SHL-naive group (63%-87%; P=.033). This difference was augmented after accounting for other surgical history and revision SHL (0%-32%, P=.019; and 46%-93%, P=.007). CONCLUSION Within a cohort of adults with CP, GMFCS levels I-III, and a mean age of 36 years, those with a history of SHL, performed a mean of 28 years prior to 3-dimensional gait analysis, walked with increased anterior pelvic tilt compared with those without a history of SHL. [Orthopedics. 202x;4x(x):xx-xx.].
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States RA, Salem Y, Krzak JJ, Godwin EM, McMulkin ML, Kaplan SL. Three-Dimensional Instrumented Gait Analysis for Children With Cerebral Palsy: An Evidence-Based Clinical Practice Guideline. Pediatr Phys Ther 2024; 36:182-206. [PMID: 38568266 DOI: 10.1097/pep.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
BACKGROUND Children with cerebral palsy (CP) who walk have complex gait patterns and deviations often requiring physical therapy (PT)/medical/surgical interventions. Walking in children with CP can be assessed with 3-dimensional instrumented gait analysis (3D-IGA) providing kinematics (joint angles), kinetics (joint moments/powers), and muscle activity. PURPOSE This clinical practice guideline provides PTs, physicians, and associated clinicians involved in the care of children with CP, with 7 action statements on when and how 3D-IGA can inform clinical assessments and potential interventions. It links the action statement grades with specific levels of evidence based on a critical appraisal of the literature. CONCLUSIONS This clinical practice guideline addresses 3D-IGA's utility to inform surgical and non-surgical interventions, to identify gait deviations among segments/joints and planes and to evaluate the effectiveness of interventions. Best practice statements provide guidance for clinicians about the preferred characteristics of 3D-IGA laboratories including instrumentation, staffing, and reporting practices.Video Abstract: Supplemental digital content available at http://links.lww.com/PPT/A524.
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Affiliation(s)
- Rebecca A States
- Physical Therapy Program, School of Health Professions and Human Services, Hofstra University, Hempstead, New York (Drs States and Salem); Faculty of Physiotherapy, Cairo University, Cairo, Egypt (Dr Salem); Midwestern University - Physical Therapy Program, Downers Grove, Illinois (Dr Krzak); Shriners Children's Chicago, Gerald F. Harris Motion Analysis Center, Chicago, Illinois (Dr Krzak); Department of Physical Therapy, Long Island University - Brooklyn, Brooklyn, New York (Dr Godwin); Shriners Children's Spokane, Walter E. & Agnes M. Griffin Motion Analysis Center, Spokane, Washington (Dr McMulkin); Department of Rehabilitation & Movement Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey (Dr Kaplan)
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Galán-Olleros M, Lerma-Lara S, Torres-Izquierdo B, Ramírez-Barragán A, Egea-Gámez RM, Hosseinzadeh P, Martínez-Caballero I. Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies. J Child Orthop 2024; 18:13-25. [PMID: 38348440 PMCID: PMC10859119 DOI: 10.1177/18632521231217542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/14/2023] [Indexed: 02/15/2024] Open
Abstract
Purpose To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait. Methods Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. Results Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = -6.39; 95% confidence interval = [-10.4, -2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = -14.27; 95% confidence interval = [-18.31, -10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = -5.6; 95% confidence interval = [-9.59, -1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation. Conclusions Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase. Level of evidence Level III, Systematic review of level III studies.
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Affiliation(s)
- María Galán-Olleros
- Neuro-Orthopaedic Unit, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sergio Lerma-Lara
- Departament of Physiotherapy, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
| | - Beltran Torres-Izquierdo
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ana Ramírez-Barragán
- Neuro-Orthopaedic Unit, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Rosa M Egea-Gámez
- Neuro-Orthopaedic Unit, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Pooya Hosseinzadeh
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ignacio Martínez-Caballero
- Neuro-Orthopaedic Unit, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Saraswat P, MacWilliams BA, McMulkin ML, Carpenter AM, Shull ER, Carroll KL, Stotts AK, Sousa T, Hyer LC, Westberry DE. Is peak hamstrings muscle-tendon length criterion a sufficient indicator to recommend against surgical lengthening of hamstrings? Gait Posture 2023; 105:149-157. [PMID: 37573759 DOI: 10.1016/j.gaitpost.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Excessive knee flexion during stance in children with cerebral palsy is often treated by surgical hamstrings lengthening. Pre-operative hamstrings muscle-tendon length can be estimated from kinematics and often used for decision making to rule out surgical lengthening if peak hamstrings muscle-tendon length is 'Not Short'. RESEARCH QUESTION If peak hamstrings muscle-tendon length is within two standard deviations of typical, is that a sufficient indicator to rule out surgical hamstrings lengthening? METHODS Three motion analysis centers retrospectively identified children with cerebral palsy, age 6-17 years, who had consecutive gait analyses with knee flexion at initial contact > 20° and popliteal angle > 35° at initial study. Three groups were considered: Medial Hamstrings Lengthening (MHL), Medial and Lateral Hamstrings Lengthening (MLHL), no surgical intervention (Control). Peak hamstrings muscle-tendon length at initial gait study was computed and categorized as 'Short' or 'Not Short'. Two outcomes variables were considered: change in peak knee extension (PKE) and change in pelvic tilt. Univariate comparisons of all variables were assessed along with a multivariate stepwise regression analysis to identify pre-operative characteristics that may predict post-operative improvement. RESULTS 440 individuals met inclusion criteria. Percentage of individuals with improved PKE by grouping were- MHL-'Short': 60%, MHL-'Not Short': 65%, MLHL-'Short': 74%, MLHL-'Not Short': 74%, Control 'Short': 20%, Control 'Not Short': 19%. Percentage of individuals with worsened pelvic tilt were- MHL-'Short': 25%, MHL-'Not Short': 11%, MLHL-'Short': 42%, MLHL-'Not Short': 21% with significantly more individuals in MHL-'Short' subgroup compared to MHL-'Not Short'. Multivariate analysis suggested that pre-operative pelvic tilt and weak hip extensor strength have the largest effect on predicting post-operative increase in APT. Peak muscle-tendon length was not a significant predictor of post-operative knee kinematics or increase in APT. SIGNIFICANCE This study suggests that hamstrings muscle-tendon length criteria by itself is not a sufficient indicator to recommend against hamstrings lengthening.
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Affiliation(s)
- Prabhav Saraswat
- Shriners Children's, Motion Analysis Center, Greenville, SC, USA.
| | - Bruce A MacWilliams
- Shriners Children's, Motion Analysis Center, Salt Lake City, UT, USA; University of Utah, Department of Orthopedic Surgery, Salt Lake City, UT, USA
| | - Mark L McMulkin
- Shriners Children's, Motion Analysis Center, Spokane, WA, USA
| | | | - Emily R Shull
- Shriners Children's, Motion Analysis Center, Greenville, SC, USA
| | - Kristen L Carroll
- Shriners Children's, Motion Analysis Center, Salt Lake City, UT, USA
| | - Alan K Stotts
- Shriners Children's, Motion Analysis Center, Salt Lake City, UT, USA; University of Utah, Department of Orthopedic Surgery, Salt Lake City, UT, USA
| | - Ted Sousa
- Shriners Children's, Motion Analysis Center, Spokane, WA, USA
| | - Lauren C Hyer
- Shriners Children's, Motion Analysis Center, Greenville, SC, USA
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Türker D, Yakut Y, Yaşar E, Kerem Günel M, Yılmaz B, Tan AK. The effects of functional electrical stimulation cycling on gait parameters in diplegic cerebral palsy: a single-blind randomized controlled trial. Somatosens Mot Res 2023; 40:62-71. [PMID: 36645809 DOI: 10.1080/08990220.2022.2157393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE To investigate the effects of functional electrical stimulation cycling (FES-C) training in addition to conventional physical therapy on gait, muscle strength, gross motor function, and energy expenditure in ambulatory children with spastic diplegic cerebral palsy. MATERIALS AND METHODS Twenty children with diplegic cerebral palsy were randomly assigned to FES-C group (n = 10) or control group (n = 10). Subjects trained 3 days/week for 8 weeks. Control group received conventional physical therapy. The FES-C group additionally received FES-C training. The functional muscle test was used for muscle strength assessment. Vicon-3D system was used for gait analysis. Gross Motor Function Measure (GMFM-88) was used for motor function assessment and calorimeter was used for energy expenditure. Measurements were performed at the baseline, at the eight week and at the sixteenth week. RESULTS Functional muscle strength, gross motor function, and energy expenditure improved more in the FES-C group after training and follow up (p < 0.05). There was no significant difference found between the changes in gait parameters of the two groups after treatment and follow up (p > 0.05). Pelvic tilt while walking decreased after training in the FES-C group (p < 0.05). CONCLUSIONS FES-C applied in addition to conventional physical therapy in children with diplegic cerebral palsy is more effective than conventional physical therapy for increasing functional muscle strength, improving gross motor function functions, and reducing energy expenditure.HighlightsFES-C improves lower extremity functional muscle strength, gross motor function, and energy expenditure in ambulatory children with spastic dCP.The use of FES-C in combination with conventional physiotherapy methods may be beneficial in outpatients with spastic dCP.
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Affiliation(s)
- Duygu Türker
- Faculty of Gülhane Physiotherapy and Rehabilitation, Department of Pediatric Rehabilitation, University of Health Sciences, Ankara, Turkey
| | - Yavuz Yakut
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Hasan Kalyoncu University, Gaziantep, Turkey
| | - Evren Yaşar
- Department of Physical Medicine and Rehabilitation, Gulhane School of Medicine, University of Health Sciences, Ankara City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
| | - Mintaze Kerem Günel
- Faculty of Physical Therapy Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Bilge Yılmaz
- Department of Physical Medicine and Rehabilitation, Gulhane School of Medicine, University of Health Sciences, Ankara City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey.,Department of Physical Medicine and Rehabilitation, Gulhane School of Medicine, University of Health Sciences, Gaziler Training and Research Hospital, Ankara, Turkey.,Department of Physical Medicine and Rehabilitation, Gulhane School of Medicine, University of Health Sciences, Gaziler Training and Research Hospital
| | - Arif Kenan Tan
- Department of Physical Medicine and Rehabilitation, Gulhane School of Medicine, University of Health Sciences, Ankara City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey.,Department of Physical Medicine and Rehabilitation, Gulhane School of Medicine, University of Health Sciences, Gaziler Training and Research Hospital, Ankara, Turkey.,Department of Physical Medicine and Rehabilitation, Gulhane School of Medicine, University of Health Sciences, Gaziler Training and Research Hospital
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Mid-Term Results of Distal Femoral Extension and Shortening Osteotomy in Treating Flexed Knee Gait in Children with Cerebral Palsy. CHILDREN 2022; 9:children9101427. [PMID: 36291363 PMCID: PMC9600012 DOI: 10.3390/children9101427] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 12/03/2022]
Abstract
Background: Distal femoral extension and shortening osteotomy (DFESO) seems to be an effective method for the treatment of flexed knee gait in children with cerebral palsy. Nevertheless, studies investigating the mid- and long-term outcomes after such procedures are lacking in the literature. Therefore, the purpose of this study was to assess the mid-term outcomes regarding sagittal plane kinematics of the knee after DFESO with or without concomitant patella advancement. Furthermore, an evaluation of the postoperative course and possible recurrence of flexed knee gait was planned. Methods: In a prospective observational study, 19 patients (28 limbs; mean age 11.8 years (6.7–16.0 years)) were examined using 3-D gait analysis and clinical exam before (E0) and at a mean of 38 months (E2: 24–55 months) after surgery. Fifteen patients (22 limbs) had an additional first postoperative gait analysis (E1) after a mean of 14 (10–20) months after surgery. In these patients, the postoperative changes between the short-term and mid-term gait analyses were evaluated. Results: DFESO led to a significant decrease in flexed knee gait with an improvement in sagittal plane kinematics during the stance phase. In addition, a slightly increased anterior pelvic tilt was observed at E1, and we found a tendency towards stiff knee gait with a decrease in mean knee flexion in swing at E2. Conclusions: DFESO led to a significant improvement in flexed knee gait in children with cerebral palsy. The therapeutic effect seems to be lasting on mid-term follow-up with a slight overall tendency to recurrence.
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Broström EW, Antonissen L, von Heideken J, Esbjörnsson AC, Hagenäs L, Naili JE. Gait in children with achondroplasia - a cross-sectional study on joint kinematics and kinetics. BMC Musculoskelet Disord 2022; 23:397. [PMID: 35484571 PMCID: PMC9047292 DOI: 10.1186/s12891-022-05343-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Children with achondroplasia have extreme short stature due to short limbs, as well as several other clinical features that may affect their gait. The purpose of this cross-sectional study was to provide a detailed description of gait in children with achondroplasia compared to age-matched controls. Methods Between the years 2007 and 2010, 16 children with achondroplasia [mean age 9.6 years (range 5–16; six female)] with no previous history of orthopaedic lower limb surgery and 19 age-matched controls conducted three-dimensional (3D) gait analysis at one occasion. The gait analysis rendered pelvis and lower limb joint kinematics and kinetics, and time and distance data. Descriptive statistics, independent samples t-tests, and Fisher’s exact test were used to describe the cohort including gait data and participant characteristics. Results Children with achondroplasia had kinematic gait pattern deviations in all three planes, especially in the sagittal plane, when compared to the control group. Peak anterior pelvic tilt and peak ankle dorsiflexion were found to be increased. Increased knee flexion was noted at initial contact and again at terminal stance. During stance, children with achondroplasia had a higher peak hip abduction angle and a higher peak knee varus angle in the frontal plane. In the sagittal plane, kinetic gait pattern deviations were found at the hip, knee, and ankle, consistent with a flexion pattern. Compared to the control group, children with achondroplasia walked with reduced walking speed and step length, and increased cadence. There was no difference in walking speed when leg length was taken into account. Normalised step length and normalised cadence, on the other hand, were found to be increased in children with achondroplasia. Conclusions The observed gait characteristics in children with achondroplasia are related to anatomical attributes and strategies to increase step length, and hence walking speed.
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Affiliation(s)
- Eva W Broström
- Department of Women's and Children's Health, Karolinska Institutet, Motoriklab, Q2:07, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Lotte Antonissen
- Faculty of Movement and Rehabilitation Sciences, Katholieke Universiteit Leuven, Tervuursevest 101, 3001, Leuven, Belgium
| | - Johan von Heideken
- Department of Women's and Children's Health, Karolinska Institutet, Motoriklab, Q2:07, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Anna-Clara Esbjörnsson
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Skane University Hospital, 221 85, Lund, Sweden
| | - Lars Hagenäs
- Department of Women's and Children's Health, Karolinska Institutet, Motoriklab, Q2:07, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Josefine E Naili
- Department of Women's and Children's Health, Karolinska Institutet, Motoriklab, Q2:07, Karolinska University Hospital, 171 76, Stockholm, Sweden
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de Freitas Guardini KM, Kawamura CM, Lopes JAF, Fujino MH, Blumetti FC, de Morais Filho MC. Factors related to better outcomes after single-event multilevel surgery (SEMLS) in patients with cerebral palsy. Gait Posture 2021; 86:260-265. [PMID: 33813186 DOI: 10.1016/j.gaitpost.2021.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/08/2021] [Accepted: 03/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Good outcomes have been described after single-event multilevel surgery (SEMLS) in cerebral palsy (CP); however, there is limited evidence regarding factors influencing them. RESEARCH QUESTION What were the factors related to kinematic outcomes after SEMLS in the present study? METHODS Two hundred and fifty-eight patients with spastic diplegic CP, GMFCS I-III, who underwent SEMLS and had done pre and post-operative gait analyses were included in the SEMLS Group (SEMLS-G). A second search was performed in the same database looking for patients to compose the Control Group (CG), and 88 subjects, with at least two gait analyses and with no surgical intervention between tests, were identified. Demographic data, GDI and GPS (Gait Profile Score) were analyzed in both groups, and the results compared. A second evaluation was performed in the SEMLS-G in order to identify the influence of age, gender, follow-up time, pre-operative GDI, GMFCS and gait velocity on results. RESULTS The GDI (51.3-58.4) and GPS (2.5°) improvement occurred only in SEMLS-G (p < 0.001). On sagittal plane, there was an improvement at the knee and ankle levels in SEMLS-G, whereas the pelvic alignment improved in the CG. In SEMLS-G, patients with improvement on GDI > 10 points had lower pre-operative GDI (46.15) than other groups (p < 0.001). In addition, patients with reduction on GDI after intervention had lower pre-operative gait velocity than subjects with improvement >10 points (p = 0. 01). The increase on GDI after SEMLS was greater in patients GMFCS I and II than GMFCS III (p = 0.003). There was a negative effect of GMFCS III on GDI improvement after intervention (p = 0.014). SIGNIFICANCE Lower pre-operative GDI, higher baseline gait velocity and GMFCS levels I and II were related to better outcomes after SEMLS in the present study. On the other hand, patients GMFCS III were more susceptible to deteriorate after SEMLS.
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Affiliation(s)
| | | | | | - Marcelo H Fujino
- Gait Laboratory and Cerebral Palsy Clinic, AACD, São Paulo, Brazil
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Kiernan D. Lower limb biomechanics during gait in children with Achondroplasia. J Biomech 2021; 119:110313. [PMID: 33631664 DOI: 10.1016/j.jbiomech.2021.110313] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/27/2021] [Accepted: 02/03/2021] [Indexed: 11/28/2022]
Abstract
Achondroplasia is an autosomal dominant disorder that has been reported to be the most common condition associated with severe disproportionate short stature. A limited number of studies exist in the literature reporting kinematic abnormalities in children with Achondroplasia. Reported deviations include increased pelvic tilt, flexed knees during stance and excessive hip abduction. However, studies lack full 3-dimensional data and results are variable. The aim of this study was to examine differences in 3-dimensional kinematics during gait between children with Achondroplasia and age-matched controls A retrospective analysis was conducted of our gait laboratory database over a 20-year period. Eight children with Achondroplasia and 32 children with typical development were included. A full 3-dimensional kinematic analysis was performed using a CODA mpx30/cx1 active marker system. Increased flexion at all joints in the sagittal plane, increased hip abduction and foot supination in the coronal plane and increased external hip rotation were present for children with Achondroplasia. In contrast to other studies, increased knee varus was not an issue for the children in this study. This study provides a full description of the kinematic patterns associated with children with Achondroplasia and, as such, a comprehensive baseline for planning rehabilitation strategies in these children.
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Affiliation(s)
- Damien Kiernan
- Movement Analysis Laboratory, Central Remedial Clinic, Clontarf, Dublin 3, Ireland.
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de Morais Filho MC, Fujino MH, Blumetti FC, Dos Santos CA, Kawamura CM, Ramos BCA, Lopes JAF. Comparison between semitendinosus transfer to distal femur and medial hamstrings surgical lengthening for treatment of flexed knee gait in cerebral palsy. J Orthop Surg (Hong Kong) 2020; 28:2309499020910978. [PMID: 32167417 DOI: 10.1177/2309499020910978] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Hamstrings surgical lengthening (HSL) has been frequently used for the treatment of flexed knee gait in cerebral palsy; however, recurrence of knee flexion deformity (KFD) and increase of anterior pelvic tilt (APT) were reported in a long-term follow-up. RESEARCH QUESTION The aim of this study was to compare semitendinosus transfer to distal femur (STTX) and semitendinosus surgical lengthening (STL) regarding the reduction of KFD and the increase of APT after flexed knee gait treatment. METHODS One hundred and eleven patients were evaluated and they were divided into two groups according to surgical procedures at knees: group A (65 patients/130 knees), including patients who received medial HSL as part of multilevel approach; group B (46 patients/92 knees), represented by patients who underwent orthopedic surgery including an STTX instead of STL. RESULTS Fixed knee flexion deformity (FKFD) decreased only in group B (from 6.79° to 2.96°, p < 0.001) after intervention. In kinematics, APT increased from 16.38° to 19.03° in group A (p = 0.003), while group B also increased from 15.26° to 20.59° (p < 0.001). The minimum knee flexion in stance phase (MKFS) reduced from 25.34° to 21.65° (p = 0.016) in group A and from 31° to 19.57° (p < 0.001) in group B. In the comparison between groups A and B, the increase of APT (p = 0.028) and reduction of FKFD (p < 0.001), popliteal angle (p = 0.001), bilateral popliteal angle (p = 0.003) and MKFS (p = 0.006) were higher after STTX than STL. CONCLUSION In the present study, patients who received STTX exhibited more improvement of knee extension at clinical examination and during gait than those who underwent to STL; however, STTX was not effective to prevent the increase of APT after flexed knee gait treatment.
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Affiliation(s)
- Mauro César de Morais Filho
- Division of Pediatric Orthopedic Surgery, Gait Laboratory and Cerebral Palsy Clinic, Association for the Care of Disabled Children, São Paulo, Brazil
| | - Marcelo Hideki Fujino
- Division of Pediatric Orthopedic Surgery, Gait Laboratory and Cerebral Palsy Clinic, Association for the Care of Disabled Children, São Paulo, Brazil
| | - Francesco Camara Blumetti
- Division of Pediatric Orthopedic Surgery, Gait Laboratory and Cerebral Palsy Clinic, Association for the Care of Disabled Children, São Paulo, Brazil
| | - Carlos Alberto Dos Santos
- Division of Pediatric Orthopedic Surgery, Cerebral Palsy Group, Institute of Orthopedics and Traumatology of Clinics Hospital, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Cátia Miyuki Kawamura
- Division of Physical Therapy, Gait Laboratory, Association for the Care of Disabled Children, São Paulo, Brazil
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Heitzmann DWW, Leboucher J, Block J, Günther M, Putz C, Götze M, Wolf SI, Alimusaj M. The influence of hip muscle strength on gait in individuals with a unilateral transfemoral amputation. PLoS One 2020; 15:e0238093. [PMID: 32877428 PMCID: PMC7467296 DOI: 10.1371/journal.pone.0238093] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 08/10/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION A unilateral transfemoral amputation (TFA) has a major impact on function. A leg-length discrepancy is the primary structural change, accompanied by the loss of lower-limb muscle volume and function. Prostheses can help individuals with a TFA to regain function, but such individuals still do not reach the functional level of unimpaired peers and exhibit gait deviations. This study gives insight into the causality between residual limb strength and gait deviations in individuals with a TFA. METHODS A convenient sample of 13 male individuals with a TFA (38.0 ± 12.6y; 179.7cm ± 6.5cm; 82.9kg ± 12.4kg) was recruited for this study. One participant with TFA was excluded, as he differed from the rest of the cohort, in residual limb length and the use of walking aids. A cohort of 18 unimpaired subjects served as a reference group (REF; nine females; 44y ± 13y; 174cm ± 9cm; 71kg ± 12kg). All participants underwent a conventional clinical gait analysis using a marker based 3D motion capture system and force platforms. Kinematics and kinetics were determined utilizing standard modelling methods. All subjects underwent a strength test, using a custom-made device to determine isometric moments of the hip joint in abduction, adduction, extension, and flexion. Peak values for maximum isometric moments for each movement direction and selected kinematic and kinetic values were derived from the results. Differences between subjects with TFA and unimpaired were compared using a Mann-Whitney U Test and associations between groups by Spearman's rank correlation. RESULTS The participants with a TFA showed a significantly lower maximum isometric moment for hip abduction (0.85 vs. 1.41 Nm/kg p < .001), adduction (0.87 vs. 1.37 Nm/kg p = .001) and flexion (0.93 vs. 1.63 Nm/kg p = .010) compared to the reference group. Typically reported gait deviations in people with a TFA were identified, i.e. significant lower cadence and increased step width. We further identified altered coronal plane hip and trunk kinematics, with significantly higher ranges of motion during involved side stance-phase. Gait kinetics of individuals with a TFA showed significantly lower peak values during stance for hip abduction, adduction and extension moments in comparison to the reference group. We identified a moderate negative correlation between maximum isometric moment for hip abduction and trunk obliquity range of motion (ρ = -0.45) for participants with a TFA, which was not significant (p = 0.14). CONCLUSION We showed that there are strength deficits in individuals with TFA and, that there are moderate correlations between gait deviations, i.e. lateral trunk lean during involved side stance and isometric hip abductor moment. The relation between maximum moments during gait and the corresponding maximum isometric moment may therefore be helpful to detect strength related compensation mechanisms. However, the moderate, non-significant correlation between lateral trunk lean and isometric hip abductor moment was the only one which corresponded directly to a gait deviation. Thus results must be interpreted with care. This study suggests that gait deviations in individuals with TFA are multifactorial and cannot be exclusively explained by their strength deficits. Future studies should explore the relationship between strength with kinematics and kinetics during gait in this population.
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Affiliation(s)
- Daniel Walter Werner Heitzmann
- Motion Analysis Lab, Department of Orthopaedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Orthopaedics and Trauma Surgery, Prosthetics and Orthotics Department, Heidelberg University Hospital, Heidelberg, Germany
- * E-mail:
| | - Julien Leboucher
- Motion Analysis Lab, Department of Orthopaedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Julia Block
- Motion Analysis Lab, Department of Orthopaedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Orthopaedics and Trauma Surgery, Prosthetics and Orthotics Department, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Cornelia Putz
- Motion Analysis Lab, Department of Orthopaedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Orthopaedics and Trauma Surgery, Prosthetics and Orthotics Department, Heidelberg University Hospital, Heidelberg, Germany
| | - Marco Götze
- Motion Analysis Lab, Department of Orthopaedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Immanuel Wolf
- Motion Analysis Lab, Department of Orthopaedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Merkur Alimusaj
- Motion Analysis Lab, Department of Orthopaedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Department of Orthopaedics and Trauma Surgery, Prosthetics and Orthotics Department, Heidelberg University Hospital, Heidelberg, Germany
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Bao H, Moal B, Vira S, Bronsard N, Amabile C, Errico T, Schwab F, Skalli W, Dubousset J, Lafage V. Spino-femoral muscles affect sagittal alignment and compensatory recruitment: a new look into soft tissues in adult spinal deformity. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2998-3005. [PMID: 32529524 DOI: 10.1007/s00586-020-06488-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/09/2020] [Accepted: 05/31/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To quantify muscle characteristics (volumes and fat infiltration) and identify their relationship to sagittal malalignment and compensatory mechanism recruitment. METHODS Female adult spinal deformity patients underwent T1-weighted MRI with a 2-point Dixon protocol from the proximal tibia up to the T12 vertebra. 3D reconstructions of 17 muscles, including extensors and flexors of spine, hip and knee, were obtained. Muscle volume standardized by bone volume and percentage of fat infiltration (Pfat) were calculated. Correlations and regressions were performed. RESULTS A total of 22 patients were included. Significant correlations were observed between sagittal alignment and muscle parameters. Fat infiltration of the hip and knee flexors and extensors correlated with larger C7-S1 SVA. Smaller spinal flexor/extensor volumes correlated with greater PI-LL mismatch (r = - 0.45 and - 0.51). Linear regression identified volume of biceps femoris as only predictor for PT (R2 = 0.34, p = 0.005) and Pfat of gluteus minimus as only predictor for SVA (R2 = 0.45, p = 0.001). Sagittally malaligned patients with larger PT (26.8° vs. 17.2°) had significantly smaller volume and larger Pfat of gluteus medius, gluteus minimus and biceps femoris, but similar values for gluteus maximus, the hip extensor. CONCLUSION This study is the first to quantify the relationship between degeneration of spino-femoral muscles and sagittal malalignment. This pathoanatomical study identifies the close relationship between gluteal, hamstring muscles and PT, SVA, which deepens our understanding of the underlying etiology that contributes to adult spinal deformity.
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Affiliation(s)
- Hongda Bao
- Hospital for Special Surgery, 535 East 70th Street, New York, 10021, USA.,Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Bertrand Moal
- Arts et Metiers ParisTech, Institut de Biomécanique Humaine Georges Charpak, Paris, France
| | - Shaleen Vira
- Hospital for Joint Diseases at NYU Langone Medical Center, New York, USA
| | - Nicolas Bronsard
- Institut Universitaire de l'Appareil Locomoteur et du Sport, University Hospital of Nice, Nice, France
| | - Celia Amabile
- Arts et Metiers ParisTech, Institut de Biomécanique Humaine Georges Charpak, Paris, France
| | - Thomas Errico
- Hospital for Joint Diseases at NYU Langone Medical Center, New York, USA
| | - Frank Schwab
- Hospital for Special Surgery, 535 East 70th Street, New York, 10021, USA
| | - Wafa Skalli
- Arts et Metiers ParisTech, Institut de Biomécanique Humaine Georges Charpak, Paris, France
| | - Jean Dubousset
- Académie Nationale de Médecine, 16 rue Bonaparte, Paris, France
| | - Virginie Lafage
- Hospital for Special Surgery, 535 East 70th Street, New York, 10021, USA.
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Contini BG, Bergamini E, Alvini M, Di Stanislao E, Di Rosa G, Castelli E, Vannozzi G, Camomilla V. A wearable gait analysis protocol to support the choice of the appropriate ankle-foot orthosis: A comparative assessment in children with Cerebral Palsy. Clin Biomech (Bristol, Avon) 2019; 70:177-185. [PMID: 31525659 DOI: 10.1016/j.clinbiomech.2019.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 07/17/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cerebral Palsy is, nowadays, the most common cause of pediatric disabilities, particularly debilitating for daily living activities. While the adoption of ankle-foot orthoses is very well established as gait treatment, the choice of the most appropriate orthotic configuration is not strongly supported by scientific evidence. The aim of this study was to develop an instrumented assessment protocol based on wearable gait analysis to support clinicians in ankle-foot orthoses configuration selection. METHODS Ten children with spastic diplegic Cerebral Palsy were assessed (7 males, aged 4 to 11 years; all functionally classified as Gross Motor Function Classification System I or II, with clinical indication of conservative treatment through use of ankle-foot orthoses). They performed a 10Meter Walk Test in three conditions: barefoot and wearing alternatively a polypropylene hinged and solid ankle-foot orthosis accommodated in the same off-the-shelf shoe model, after 20 days of daily use of each configuration. An instrumented assessment protocol based on body-mounted magneto-inertial sensors was devised to derive spatio-temporal, gait stability and symmetry biomechanical parameters within an observational pre and post cross over design. FINDINGS The analysis at the individual level quantitatively revealed how different patients benefited differently from the two orthoses. No general indications were obtained in favour of or against a specific configuration for the sample as a whole. INTERPRETATION The proposed instrumented protocol represents a quantitative and useful tool to support the clinical selection of an appropriate orthotic treatment and, potentially, in evaluating its effectiveness.
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Affiliation(s)
- Bruno Giuseppe Contini
- Division of Pediatric Neurorehabilitation, "Ospedale Pediatrico Bambino Gesù", Rome, Italy
| | - Elena Bergamini
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome "Foro Italico", Rome, Italy; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Piazza de Bosis 15, 00135 Rome, Italy.
| | | | - Eugenio Di Stanislao
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome "Foro Italico", Rome, Italy; ITOP SpA Officine Ortopediche, Palestrina (Rome), Italy.
| | - Giuseppe Di Rosa
- Division of Pediatric Neurorehabilitation, "Ospedale Pediatrico Bambino Gesù", Rome, Italy.
| | - Enrico Castelli
- Division of Pediatric Neurorehabilitation, "Ospedale Pediatrico Bambino Gesù", Rome, Italy.
| | - Giuseppe Vannozzi
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome "Foro Italico", Rome, Italy; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Piazza de Bosis 15, 00135 Rome, Italy.
| | - Valentina Camomilla
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome "Foro Italico", Rome, Italy; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Piazza de Bosis 15, 00135 Rome, Italy.
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Papageorgiou E, Simon-Martinez C, Molenaers G, Ortibus E, Van Campenhout A, Desloovere K. Are spasticity, weakness, selectivity, and passive range of motion related to gait deviations in children with spastic cerebral palsy? A statistical parametric mapping study. PLoS One 2019; 14:e0223363. [PMID: 31603897 PMCID: PMC6788679 DOI: 10.1371/journal.pone.0223363] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/19/2019] [Indexed: 01/17/2023] Open
Abstract
This study aimed to identify the relationships between clinical impairments and gait deviations in children with cerebral palsy (CP). A retrospective convenience sample of 367 children with CP was selected (3–18 years old) and divided in two groups based on clinical symptomatology [unilateral (uCP) / bilateral CP (bCP), (n = 167/200)]. All children underwent a three-dimensional gait analysis and a standardized clinical examination. Gait was inspected on a vector level (all sagittal motions combined), and an individual joint level (pelvis, hip, knee and ankle joint motions). Statistical non-parametric mapping was applied to identify specific parts of the gait cycle displaying relationships between the gait deviations of both groups and the impairment scores of spasticity, weakness, selectivity, and passive range of motion. Impairment scores were summarized in two ways: a) composite impairment scores (e.g. combined spasticity of all assessed muscles acting around the hip, knee and ankle joints) and b) joint specific impairment scores (e.g. spasticity of the muscles acting around the knee joint). Results showed that the vector and most of the individual motions were related to the composite scores. Direct and carry-over relationships were found between certain individual motions and joint impairment scores (around the same or neighboring joints, respectively). All correlations were more prominent for children with bCP compared to uCP, especially regarding the relationships of gait deviations with weakness and reduced selectivity. In conclusion, this study enabled the mapping of relationships between clinical impairments and gait deviations in children with CP, by identifying specific parts of the gait cycle that are related to each of these impairments. These results provide a comprehensive description of these relationships, while simultaneously highlighting the differences between the two CP groups. Integration of these findings could lead to a better understanding of the pathophysiology of gait deviations and, eventually, support individualized treatment planning.
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Affiliation(s)
- Eirini Papageorgiou
- KU Leuven Department of Rehabilitation Sciences, Leuven, Belgium
- Clinical Motion Analysis Laboratory, University Hospitals Leuven, Leuven, Belgium
- * E-mail:
| | | | - Guy Molenaers
- KU Leuven Department of Development and Regeneration, Leuven, Belgium
- Department of Orthopedics, University Hospitals Leuven, Leuven, Belgium
| | - Els Ortibus
- KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - Anja Van Campenhout
- KU Leuven Department of Development and Regeneration, Leuven, Belgium
- Department of Orthopedics, University Hospitals Leuven, Leuven, Belgium
| | - Kaat Desloovere
- KU Leuven Department of Rehabilitation Sciences, Leuven, Belgium
- Clinical Motion Analysis Laboratory, University Hospitals Leuven, Leuven, Belgium
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Distal Femoral Shortening Osteotomy for Severe Knee Flexion Contracture and Crouch Gait in Cerebral Palsy. J Clin Med 2019; 8:jcm8091354. [PMID: 31480593 PMCID: PMC6780050 DOI: 10.3390/jcm8091354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 08/24/2019] [Accepted: 08/29/2019] [Indexed: 11/17/2022] Open
Abstract
Although there have been advancements of surgical techniques to correct gait abnormalities seen in patients with cerebral palsy, the crouch gait remains one of the most difficult problems to treat. The purpose of this retrospective study was to examine our results of distal femoral shortening osteotomy (DFSO) and patellar tendon advancement (PTA), performed in patients with crouch gait associated with severe knee flexion contracture. A total of 33 patients with a mean fixed knee contracture of 38° were included in the study. The mean age at the time of surgery was 12.2 years and the mean follow-up was 26.9 months. The measurements of clinical, radiological, and gait parameters were performed before and after surgery. The mean degrees of knee flexion contracture, Koshino index of patella height, and Gait Deviation Index were found to be significantly improved at the time of final follow-up. The maximum knee extension during the stance phase improved by an average of 25°, and the range of knee motion during gait increased postoperatively. On the other hand, the mean anterior pelvic tilt increased by 9.9°. Also, the maximum knee flexion during the swing phase decreased and the timing of peak knee flexion was observed to be delayed. We conclude that combined procedure of DFSO and PTA is an effective and safe surgical method for treating severe knee flexion contracture and crouch gait. However, the surgeons should be aware of the development of increased anterior pelvic tilt and stiff knee gait after the index operation.
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17
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The increase of anterior pelvic tilt after semitendinosus transfer to distal femur in patients with spastic diplegic cerebral palsy. J Pediatr Orthop B 2019; 28:327-331. [PMID: 30499862 DOI: 10.1097/bpb.0000000000000577] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to compare semitendinosus transfer to distal femur (STTX) to semitendinosus surgical lengthening (STL) regarding the increase of anterior pelvic tilt after flexed knee gait treatment. Thirty-nine patients were evaluated, and they were divided according surgical procedures at knees: STL group (22 patients/44 knees), which included patients who received medial hamstrings surgical lengthening as part of multilevel approach, and STTX group (17 patients/34 knees), which was represented by patients who underwent orthopedic surgery including a STTX instead of STL. In the present study, the mean anterior pelvic tilt increased in all groups after treatment and STTX was not effective to prevent it in a medium-term follow-up.
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Yılmaz Topçuoğlu MS, Krautwurst BK, Klotz M, Dreher T, Wolf SI. How do children with bilateral spastic cerebral palsy manage walking on inclines? Gait Posture 2018; 66:172-180. [PMID: 30195221 DOI: 10.1016/j.gaitpost.2018.08.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/27/2018] [Accepted: 08/27/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Walking on inclined surfaces is an everyday task, which challenges stability and propulsion even in healthy adults. Children with cerebral palsy adapt similarly to inclines like healthy children do. However, how stability and propulsion in these subjects are influenced by different inclines remained unaddressed as of yet. RESEARCH QUESTION The aim was to examine the feeling of safety, stability and propulsion of children with cerebral palsy when walking on inclines to gain insight into the challenges they might face on these conditions. METHODS Eighteen children with bilateral spastic cerebral palsy with gross motor function classification scale level I and II and nineteen healthy children underwent instrumented 3D gait analysis on level ground and on a 5° and a 10° incline. A mixed linear model was used to draw between and within group comparisons. RESULTS Reduced lateral trunk sway, a relative lengthening of the lower limb at initial contact and a controlled walking speed were employed during downhill gait compared to level walking. Patients showed an increased sagittal ROM of trunk (3-4°) and pelvis (2-3°) and a decreased sagittal knee ROM (13°) compared to the typically developed children. During uphill gait, an insufficient increase of push-off power at the ankle (increase by 0.48 W/kg) was noted in children with CP, which appeared to lead to particularly shorter strides (about 0.1 m) in patients compared to healthy children (increase by 1.32 W/kg). SIGNIFICANCE Depending on inclination angle, children with cerebral palsy managed to walk on inclines in a controlled manner. The steeper the incline, the more the gait appeared to be affected: decreased feeling of safety, increased need for stabilising mechanisms for downhill gait and less sufficient uphill propulsion were seen. Helping these patients to attain better control during downhill gait and strengthening uphill gait mechanisms may support their participation in everyday life.
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Affiliation(s)
- Miray-Su Yılmaz Topçuoğlu
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Britta K Krautwurst
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Matthias Klotz
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Thomas Dreher
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Sebastian I Wolf
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
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The increase of anterior pelvic tilt after crouch gait treatment in patients with cerebral palsy. Gait Posture 2018; 63:165-170. [PMID: 29753172 DOI: 10.1016/j.gaitpost.2018.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 03/27/2018] [Accepted: 05/04/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The increase of anterior pelvic tilt (APT) has been described after the treatment of crouch gait in cerebral palsy (CP). The ideal treatment option for flexed knee gait in CP should provide knee extension improvement in the stance phase without generating the increase of APT. RESEARCH QUESTION The purpose of this study was to compare three different approaches used for the treatment of crouch gait in CP [distal femur extension osteotomy (DFEO), patellar tendon shortening (PTS) and the combination of DFEO +PTS] regarding the increase of APT after the interventions. METHODS The inclusion criteria were: (1) diagnosis of spastic diplegic CP, (2) GMFCS levels I-III, (3) patients who underwent DFEO and/or PTS and (4) with complete documentation in the gait laboratory before and after the intervention. The included patients were divided into 3 groups, according to the procedures performed for crouch gait treatment: PTS (19 patients), DFEO (54 patients) and PTS + DFEO (22 patients). RESULTS During stance phase, knee flexion decreased from 41.60 to 13.60 in the PTS group (p < 0.001), from 46.00 to 30.70 in the DFEO group (p < 0.001) and from 52.30 to 29.50 in the PTS + DFEO group (p < 0.001). APT increased 140 (p < 0.001) in the PTS group, 7.1° (p < 0.001) in the DFEO group and 6.60 (p < 0.001) in the PTS + DFEO group after surgical intervention. The PTS group presented a more significant deterioration of pelvic tilt than the DFEO (p = 0.002) and PTS + DFEO (p = 0.001) groups. The increase of APT was higher when HSL was also performed in the PTS + DFEO group (p = 0.016). SIGNIFICANCE The increase of APT was observed in all studied groups, but it was more significant for those who underwent a PTS. The inclusion of HSL in the surgical plan was related a higher increase of APT in the PTS + DFEO group.
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Steppacher R, North D, Künzle C, Lengnick H, Klima H, Mündermann A, Wegener R. Retrospective Evaluation of Changes in Gait Patterns in Children and Adolescents With Cerebral Palsy After Multilevel Surgery. J Child Neurol 2018; 33:453-462. [PMID: 29683017 DOI: 10.1177/0883073818766681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to retrospectively investigate changes in gait patterns after single-event multilevel surgery in children and adolescents with bilateral cerebral palsy. Three-dimensional instrumented pre- and postoperative gait data of 12 patients were compared to data of 12 healthy control subjects using principal component analysis to reduce the dimensionality of kinematic and kinetic gait data and detect gait differences. The differences between pre- and postoperative data and between postoperative data and data of control subjects were calculated using a linear mixed model. The results revealed 14 significant effects for pre- and postoperative waveforms and 11 significant effects for postoperative and control waveforms. Patients after single-event multilevel surgery walked with smaller internal foot progression angle throughout the gait cycle, lower knee flexion at initial swing, and earlier knee extension during terminal swing. Retained gait deviations included excessive pelvic tilt and internally rotated and flexed hips over the entire gait cycle. Contrary to our hypothesis, postoperative waveforms in the sagittal plane differed more from control waveforms than from preoperative waveforms. These results emphasize the importance of carefully planning further conservative therapy 2 years after single-event multilevel surgery.
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Affiliation(s)
- Ramona Steppacher
- 1 Zurich University of Applied Sciences, School of Health Professions, Institute of Physiotherapy, Winterthur, Switzerland.,2 Laboratory for Motion Analysis, Department of Paediatric Orthopaedics, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - David North
- 2 Laboratory for Motion Analysis, Department of Paediatric Orthopaedics, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Christoph Künzle
- 3 Department of Paediatric Orthopaedics, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Harald Lengnick
- 3 Department of Paediatric Orthopaedics, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Harry Klima
- 3 Department of Paediatric Orthopaedics, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Annegret Mündermann
- 4 Clinic of Traumatology and Orthopaedics, University Hospital Basel, Basel, Switzerland.,5 Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Regina Wegener
- 2 Laboratory for Motion Analysis, Department of Paediatric Orthopaedics, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
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Luna N, Lucareli P, Sales V, Speciali D, Alonso A, Peterson M, Rodrigues R, Fonoffc E, Barbosac E, Teixeira M, Greve J. Treadmill training in Parkinson’s patients after deep brain stimulation: Effects on gait kinematic. NeuroRehabilitation 2018; 42:149-158. [DOI: 10.3233/nre-172267] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- N.M.S. Luna
- Post Graduate Program in Aging Science, São Judas Tadeu University (USJT), São Paulo, Brazil
- Department of Orthopedics and Traumatology, Laboratory for the Study of Movement, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - P.R.G. Lucareli
- Department of Physiotherapy, University Nove de julho, São Paulo, Brazil
| | - V.C. Sales
- Department of Orthopedics and Traumatology, Laboratory for the Study of Movement, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - D. Speciali
- Department of Orthopedics and Traumatology, Laboratory for the Study of Movement, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - A.C. Alonso
- Post Graduate Program in Aging Science, São Judas Tadeu University (USJT), São Paulo, Brazil
- Department of Orthopedics and Traumatology, Laboratory for the Study of Movement, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - M.D. Peterson
- Department of Physical Medicine and Rehabilitation, University of Michigan-Medicine, Ann Arbor, MI, USA
| | - R.B.M. Rodrigues
- Department of Neurology, Division of Functional Neurosurgery, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - E.T. Fonoffc
- Department of Neurology, Division of Functional Neurosurgery, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - E.R. Barbosac
- Department of Neurology, Division of Functional Neurosurgery, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - M.J. Teixeira
- Department of Neurology, Division of Functional Neurosurgery, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - J.M.D.A. Greve
- Department of Orthopedics and Traumatology, Laboratory for the Study of Movement, School of Medicine, University of São Paulo, São Paulo, Brazil
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Böhm H, Hösl M, Döderlein L. Predictors for anterior pelvic tilt following surgical correction of flexed knee gait including patellar tendon shortening in children with cerebral palsy. Gait Posture 2017; 54:8-14. [PMID: 28242571 DOI: 10.1016/j.gaitpost.2017.02.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 02/06/2017] [Accepted: 02/19/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patellar tendon shortening procedure within single event multilevel surgeries was shown to improve crouch gait in Cerebral Palsy (CP) patients. However, one of the drawbacks associated to the correction of flexed knee gait may be increased pelvic anterior tilt with compensatory lumbar lordosis. RESEARCH QUESTION Which CP patients are at risk for excessive anterior pelvic tilt following correction of flexed knee gait including patellar tendon shortening? METHODS 32 patients with CP between 8 and 18 years GMFCS I&II were included. They received patellar tendon shortenings within multilevel surgery. Patients with concomitant knee flexor lengthening were excluded. Gait analysis and clinical testing was performed pre- and 24.1 (SD=1.9) months postoperatively. Patients were subdivided into more/less than 5° increase in anterior pelvic tilt. Preoperative measures indicating m. rectus and m. psoas shortness, knee flexor over-length, hip extensor and abdominal muscle weakness and equinus gait were compared between groups. Stepwise multilinear regression of the response value increase in pelvic tilt during stance phase was performed from parameters that were significantly different between groups. RESULTS 34% of patients showed more than 5° increased pelvic anterior tilt postoperatively. Best predictors for anterior pelvic tilt from preoperative measures were increased m. rectus tone and reduced hip extension during walking that explained together 39% of the variance in increase of anterior pelvic tilt. DISCUSSION Every third patient showed considerable increased pelvic tilt following surgery of flexed knee gait. In particular patients with preoperative higher muscle tone in m. rectus and lower hip extension during walking were at risk and both features need to be addressed in the therapy.
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Affiliation(s)
- Harald Böhm
- Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH, Bernauerstr. 18, 83229 Aschau i. Chiemgau, Germany.
| | - Matthias Hösl
- Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH, Bernauerstr. 18, 83229 Aschau i. Chiemgau, Germany
| | - Leonhard Döderlein
- Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH, Bernauerstr. 18, 83229 Aschau i. Chiemgau, Germany
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Position Between Trunk and Pelvis During Gait Depending on the Gross Motor Function Classification System. Pediatr Phys Ther 2017; 29:130-137. [PMID: 28319490 DOI: 10.1097/pep.0000000000000361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To understand whether there is a trunk postural control threshold in the sagittal plane for the transition between the Gross Motor Function Classification System (GMFCS) levels measured with 3-dimensional gait analysis. METHOD Kinematics from 97 children with spastic bilateral cerebral palsy from spine angles according to Plug-In Gait model (Vicon) were plotted relative to their GMFCS level. RESULTS Only average and minimum values of the lumbar spine segment correlated with GMFCS levels. Maximal values at loading response correlated independently with age at all functional levels. Average and minimum values were significant when analyzing age in combination with GMFCS level. CONCLUSION There are specific postural control patterns in the average and minimum values for the position between trunk and pelvis in the sagittal plane during gait, for the transition among GMFCS I-III levels. Higher classifications of gross motor skills correlate with more extended spine angles.
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Dynamic global sagittal alignment evaluated by three-dimensional gait analysis in patients with degenerative lumbar kyphoscoliosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:2572-9. [DOI: 10.1007/s00586-016-4648-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 05/31/2016] [Accepted: 06/01/2016] [Indexed: 01/08/2023]
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Krautwurst BK, Dreher T, Wolf SI. The impact of walking devices on kinematics in patients with spastic bilateral cerebral palsy. Gait Posture 2016; 46:184-7. [PMID: 27131199 DOI: 10.1016/j.gaitpost.2016.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 02/18/2016] [Accepted: 03/20/2016] [Indexed: 02/02/2023]
Abstract
Increased anterior pelvic and trunk tilt is a common finding in patients with bilateral cerebral palsy especially during walking with assistive devices. As previous studies demonstrate various gait alterations when using assistive devices, the assessment of surgical interventions may be biased when the patients become independent of (or dependent on) assistive devices after therapy. Furthermore, some of these patients in fact are able to walk without devices even though in daily life they prefer to use them. Consequently, for such patients the classification into GMFCS level II or III may be ambiguous. The specific aim of this study was therefore to assess the influence of the use of forearm crutches and posterior walker during walking and to set this influence in relation to outcome effects of surgical intervention studies. 26 ambulatory patients with spastic bilateral CP (GMFCS II-III) were included who underwent 3D gait analysis. All patients used forearm crutches or posterior walkers in everyday life even though they were able to walk without assistive devices for short distances. Independent of the type of assistive devices, the patients walk on average with more anterior trunk tilt and pelvic tilt (7°±6° and 3°±2°) and with a maximum ankle dorsiflexion decreased by 2° (±3°) when walking with assistive devices, enhancing the mal-positioning present without device. Oppositely, the knees on average are more extended by 6° (±4°) when using the assistive devices. These effects have to be taken into account when assessing gait patterns or when monitoring the outcome after intervention as assistive devices may partially hide or exaggerate therapeutic effects.
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Affiliation(s)
- Britta K Krautwurst
- Heidelberg University Clinics, Department for Orthopedics and Trauma Surgery, Schlierbacher Landstraße 200a, 66118 Heidelberg, Germany.
| | - Thomas Dreher
- Heidelberg University Clinics, Department for Orthopedics and Trauma Surgery, Schlierbacher Landstraße 200a, 66118 Heidelberg, Germany.
| | - Sebastian I Wolf
- Heidelberg University Clinics, Department for Orthopedics and Trauma Surgery, Schlierbacher Landstraße 200a, 66118 Heidelberg, Germany.
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