Pathophysiology of juvenile idiopathic arthritis induced pes planovalgus in static and walking condition: a functional view using 3D gait analysis

[Analysis of movement disorders in paediatric and adolescent rheumatology]

Rheumatic diseases in childhood and adolescence like juvenile idiopathic arthritis can cause movement disorders due to pain, swelling and limited range of motion. This article describes different possibilities and results of movement analysis for rheumatic diseases. The influence of JIA on specific movements in individual joints and complex movements such as gait is examined. The results of gait analyses show a great influence of the disease on spatiotemporal parameters such as gait speed, cadence and stride length, on joint angles during walking and on torques and forces. Furthermore, the importance of gait analysis for estimating the efficacy of interventions like intra-articular steroids is described. This article provides a summary of current studies on the effects of rheumatic diseases on movement disorders in children and adolescents, as well as an outlook on the increasing importance of movement analysis for therapy monitoring and optimisation.

Analysis of Static Plantar Pressures in School-Age Children with and without Functional Hallux Limitus: A Case-Control Study

BACKGROUND

The presence of hallux limitus in adulthood is frequently encountered in clinical practice, generating other biomechanical, structural, and functional compensations in dynamics secondary to blockage of the main pivot in the sagittal plane, the first metatarsophalangeal joint. In addition, the presence of functional hallux limitus (FHL) in school-age children is also increasing. Currently, there is a lack of scientific literature about this condition in the pediatric population, and early diagnosis is necessary to reduce future biomechanical disorders and avoid the development of foot arthritis. The purpose of this research was to identify static plantar pressures in school-age children with and without hallux limitus.

METHODS

A total sample of 106 children aged between six and twelve years old was divided into two groups: the case group (53 subjects with functional hallux limitus) and the control group (53 subjects without functional hallux limitus). Data were acquired with the participants in a standing barefoot position on the pressure platform, and the hallux limitus functional test was performed in a sitting position to classify the individuals into the determined study group. The variables analyzed in the research were: plantar pressure, bilateral forefoot and rearfoot surface area, bilateral forefoot and rearfoot ground reaction forces, bilateral forefoot and rearfoot distribution of body weight, total left and right surface area, maximum pressure of the left foot and right foot, medium pressure of the left foot and right foot, ground reaction forces of the left foot and right foot, and the weight of each foot.

RESULTS

Age was the only descriptive quantitative variable that showed a significant difference between the two study groups, with a p-value of 0.031. No statistically significant differences were found between groups in the bilateral forefoot and rearfoot surface area, ground reaction forces, distribution of body weight, or maximum and medium plantar pressure in the left and right foot.

CONCLUSIONS

Changes in the location of the maximum pressure were observed, particularly in older participants with FHL, but these results were not significant. The findings of this study did not show significant differences between the static plantar pressures of school-age individuals with and without functional hallux limitus.

Gait parameters, functional performance and physical activity in active and inactive Juvenile Idiopathic Arthritis

BACKGROUND

Children with Juvenile Idiopathic Arthritis (JIA) may adopt different movement patterns and participate in physical activity during different states of disease.

RESEARCH QUESTION

Which specific features of gait and physical function performance differ among children with active or inactive JIA compared to healthy children?

METHODS

Forty-three children participated (14.5 ± 4.2 yrs; 60 % female). 3D-motion analysis methods were coupled with force measures from an instrumented treadmill captured gait mechanical measures. The 30-second Chair Rise Test (repetitions) and stair ascent-descent tests were performed, and the 11-point Wong-Baker face scale assessed pain after each test.

RESULTS

Compared to healthy controls children with active and inactive JIA had worse outcomes (12-21 % slower self-selected and fast walking speeds, 28-34 % slower stair navigation times, 28 % fewer chair rise repetitions in 30 s; all p < .05). Children with active JIA had 8-13 % slower gait speeds, 4 % fewer chair rise repetitions and 14-16 % slower stair navigation times. At faster walking speed, children with active JIA had less hip joint flexion/extension excursion in the sagittal plane during the gait cycle, produced higher leg stiffness, and demonstrated greater interlimb asymmetry in GRF vertical impulse during loading than healthy children (all p < .05). The Pedi-FABS subscore of "Duration: performing athletic activity for as long as you would like without stopping" was rated lower in children with active JIA compared to controls (p < .05).

CONCLUSION

Gait speed, specific load-bearing functional tasks and leg stiffness features of gait may be informative 'functional biomarkers' for assessing JIA burden and tracking treatment efficacy. Additional prospective studies are needed to determine how these features change over time with pain change, and understand impact on quality of life and physical activity participation.

The relationships of kinesiophobia and physical function and physical activity level in juvenile idiopathic arthritis

BACKGROUND

Kinesiophobia may hinder physical performance measures and functional quality of life in children with juvenile idiopathic arthritis (JIA). This study aims to quantify differences in physical function in patients with JIA compared to healthy controls, and determine the effects of kinesiophobia on physical function and physical activity.

METHODS

This was a comparative study of participants with JIA and healthy controls (JIA n = 26, control n = 17). All children with JIA had lower extremity joint involvement. Performance-based measures included gait speed, chair and stair navigation performance. Self-reported measures included Patient Reported Outcome Measurement Information System (PROMIS®) Physical Function Mobility, and Pain Interference and the Pediatric Functional Activity Brief Scale (Pedi-FABS). The Tampa Scale of Kinesiophobia (TSK-11) assessed patient fear of movement due to pain. Linear regression models were used to determine the contribution of TSK-11 scores on performance test and Pedi-FABS scores.

RESULTS

Gait speeds were 11-15% slower, chair rise repetitions were 28% fewer, and stair ascent and descent times were 26-31% slower in JIA than controls (p < .05). PROMIS® Physical Function Mobility scores were 10% lower and Pain Interference scores were 2.6 times higher in JIA than healthy controls (p = .003). TSK-11 scores were higher in JIA than controls (p < .0001). After controlling for covariates, TSK-11 scores explained 11.7-26.5% of the variance of regression models for stair climb time, chair rise performance and Pedi-FABS scores (p < .05).

CONCLUSIONS

Children with JIA experience difficulty with tasks related to body transfers. Kinesiophobia is a significant contributor to the functional task performance and may impact clinical outcomes.

Effect of customised preformed foot orthoses on gait parameters in children with juvenile idiopathic arthritis: A multicentre randomised clinical trial

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) can experience significant physical impairment of the lower extremity. Prolonged joint disease and symptoms may cause gait alterations such as reduced walking speed and increased plantar pressures in diseased areas of their feet. There is limited robust clinical trials investigating the effect of non-invasive mechanical therapies such as foot orthoses (FOs) on improving gait parameters in children with JIA.

RESEARCH QUESTION

Are customised preformed FOs effective in improving gait parameters in children with JIA?

METHODS

A multicentre, parallel design, single-blinded randomised clinical trial was used to assess the gait impacts of customised preformed FOs on children with JIA. Children with a diagnosis of JIA, exhibiting lower limb symptoms and aged 5-18 were eligible. The trial group received a low-density full length, Slimflex Simple device which was customised chair side and the control group received a sham device. Peak pressure and pressure time integrals were used as the main gait outcomes and were measured using portable Tekscan gait analysis technology at baseline, 3 and 6 months. Differences at each follow-up were assessed using the Wilcoxon rank sum test.

RESULTS

66 participants were recruited. Customised preformed FOs were effective in altering plantar pressures in children with JIA versus a control device. Reductions of peak pressures and pressure time integrals in the heel, forefoot and 5th metatarsophalangeal joint were statistically significant in favour of the trial group. This was associated with statistically significant increased midfoot contact with the trial device at baseline, 3 and 6-month data collections. The trial intervention was safe and well accepted by participants, which is reflected in the high retention rate (92%).

SIGNIFICANCE

Clinicians may prescribe customised preformed FOs in children with JIA to deflect pressure from painful joints and redistribute from high pressure areas such as the rearfoot and forefoot.

Pedobarographic outcome after subtalar screw arthroereisis in flexible juvenile flatfoot

BACKGROUND

Flatfoot is a frequent skeletal deformity in childhood that can be minimally invasively treated by arthroereisis.

QUESTION

Does the motion of juvenile flexible flatfoot normalize after arthroereisis?

METHOD

Pedographic measurements were obtained from 39 patients preoperatively, six months postoperatively and compared to a healthy group. The footprints were divided into 8 areas. The selected parameters were: contact area and force-time-integral.

RESULTS

After surgery, a load shift from the medial to the lateral areas was detected under the midfoot and forefoot. The force-time-integral under the hallux normalized. However, under the lateral midfoot, the postoperative force-time-integral was significantly higher than in the control group.

SIGNIFICANCE

The study shows that arthroereisis is able to correct the medially displaced load distribution of juvenile flexible flatfoot. However, further investigations are required to find out if the higher punctual loading under the lateral midfoot may cause problems in the long term.

Juvenile idiopathic arthritis, gait characteristics and relation to function

BACKGROUND

Juvenile Idiopathic Arthritis (JIA) is a chronic inflammatory arthritis that impacts biomechanical features of gait. This systematic review describes the effects of JIA on gait motion parameters and walking performance.

METHODS

Six databases were searched (PubMed/Medline, Cochrane, the EBSCOHost database SPORTDiscus, Web of Science, and Embase). Studies were restricted to children with any subtype of JIA who were assessed for gait motion features (kinematic, kinetic, temporalspatial) or walking performance (velocity or distance covered); could include intervention or treatment exposure with measures of gait and gait speed; could involve comparison of gait in JIA to healthy controls. Quality of evidence was assessed using the GRADE system. This systematic review was registered at PROSPERO (CRD42018109582) RESULTS: The search yielded 625 papers, 23 of which described biomechanical features of gait and/or assessed walking performance. Twenty studies measured walking velocity and walking ability using simple field tests or laboratory methods. Eleven studies measured temporalspatial parameters such as cadence, step length, stride length, step width, single and double support time. Nine studies evaluated kinetic measurements including joint power, flexion and extension and joint moments. Nine studies evaluated kinematic parameters including range of motion, pelvic tilt, center of motion and trunk sway.

CONCLUSIONS

Key features of gait in children with JIA include slower gait velocity, shortened step length, decreased range of motion at the hip, knee and ankle with trend towards flexion, decreased joint power, anteriorly tilted pelvis and trunk with shifted center of motion. There is a potential to ameliorate JIA-related gait changes with exercise and/or pharmaceutical interventions.

Linking Joint Impairment and Gait Biomechanics in Patients with Juvenile Idiopathic Arthritis

Juvenile Idiopathic Arthritis (JIA) is a paediatric musculoskeletal disease of unknown aetiology, leading to walking alterations when the lower-limb joints are involved. Diagnosis of JIA is mostly clinical. Imaging can quantify impairments associated to inflammation and joint damage. However, treatment planning could be better supported using dynamic information, such as joint contact forces (JCFs). To this purpose, we used a musculoskeletal model to predict JCFs and investigate how JCFs varied as a result of joint impairment in eighteen children with JIA. Gait analysis data and magnetic resonance images (MRI) were used to develop patient-specific lower-limb musculoskeletal models, which were evaluated for operator-dependent variability (< 3.6°, 0.05 N kg-1 and 0.5 BW for joint angles, moments, and JCFs, respectively). Gait alterations and JCF patterns showed high between-subjects variability reflecting the pathology heterogeneity in the cohort. Higher joint impairment, assessed with MRI-based evaluation, was weakly associated to overall joint overloading. A stronger correlation was observed between impairment of one limb and overload of the contralateral limb, suggesting risky compensatory strategies being adopted, especially at the knee level. This suggests that knee overloading during gait might be a good predictor of disease progression and gait biomechanics should be used to inform treatment planning.

Multi-segment foot models and their use in clinical populations

BACKGROUND

Many multi-segment foot models based on skin-markers have been proposed for in-vivo kinematic analysis of foot joints. It remains unclear whether these models have developed far enough to be useful in clinical populations. The present paper aims at reviewing these models, by discussing major methodological issues, and analyzing relevant clinical applications.

RESEARCH QUESTION

Can multi-segment foot models be used in clinical populations?

METHODS

Pubmed and Google Scholar were used as the main search engines to perform an extensive literature search of papers reporting definition, validation or application studies of multi-segment foot models. The search keywords were the following: 'multisegment'; 'foot'; 'model'; 'kinematics', 'joints' and 'gait'.

RESULTS

More than 100 papers published between 1991 and 2018 were identified and included in the review. These studies either described a technique or reported a clinical application of one of nearly 40 models which differed according to the number of segments, bony landmarks, marker set, definition of anatomical frames, and convention for calculation of joint rotations. Only a few of these models have undergone robust validation studies. Clinical application papers divided by type of assessment revealed that the large majority of studies were a cross-sectional comparison of a pathological group to a control population.

SIGNIFICANCE

This review suggests that there is sufficient evidence that multi-segment foot models may be successfully applied in clinical populations. Analysis of the currently available models allows users to better identify the most suitable protocol for specific clinical applications. However new models require thorough validation and assessment before being used to support clinical decisions.

Self-rated walking disability and dynamic ankle joint stiffness in children and adolescents with Juvenile Idiopathic Arthritis receiving intraarticular corticosteroid joint injections of the foot

BACKGROUND

Children and adolescents with Juvenile Idiopathic Arthritis (JIA) exhibit deviations in ankle dynamic joint stiffness (DJS, or moment-angle relationship) compared to healthy peers, but the relationship between ankle DJS and self-reported walking impairments has not been studied. This secondary analysis aimed to investigate the relationship between ankle DJS and self-reported walking disability in juveniles with JIA, and to determine whether intraarticular corticosteroid foot injections (IACI) were associated with long term changes in ankle DJS.

RESEARCH QUESTIONS

Is ankle DJS altered in children with JIA reporting walking difficulties compared to children with JIA reporting no walking difficulties? Are IACIs associated with persistent alterations in ankle DJS?

METHODS

Gait dynamics (DJS), foot pain, and foot-related disability were assessed in 33 children with JIA before intraarticular corticoid foot injection (IACI), and three months after IACI. Using self-reported walking capacity scores, children were classified as either having no walking difficulties (ND) or having walking difficulties (WD). Inferential statistics were used to compare demographics, pain, impairment scores, and ankle DJS between the groups.

RESULTS

Before treatment, in the WD group, ankle DJS was significantly decreased both in the early rising phase (ERP = 0.03+0.02 vs. 0.05+0.02 Nm(kg*deg)^{- 1}) and late rising phase (LRP = 0.11+0.06 vs. 0.24+0.22 Nm(kg*deg)^-1) compared to the ND group. At three months, the ERP was still significantly decreased in the WD group (ERP = 0.03+0.01 vs. 0.05+0.03 Nm(kg*deg)^-1).

SIGNIFICANCE

Among children and adolescents with JIA who reported walking difficulties prior to IACIs, alterations in DJS in early stance phase (decreased ERP) remained three months after IACI suggesting persistent gait adaptations, possibly related to pain. Pre-treatment gait analysis may aid in identifying children who will not have long term benefit from IACIs in terms of improved gait, and therefore, may be informed and have the choice to be spared the risk of side effects associated with this treatment.

Effect of knee unloading shoes on regional plantar forces in people with symptomatic knee osteoarthritis - an exploratory study

Background

Knee 'unloading' footwear can reduce the external knee adduction moment in people with knee osteoarthritis, yet effects of these shoes on regional plantar forces are unknown. We evaluated the effects of unloading shoes on in-shoe regional plantar forces, and whether measures of foot posture and/or mobility moderate these effects in people with symptomatic knee osteoarthritis.

Methods

In this exploratory study 21 participants underwent testing while wearing knee unloading shoes (ASICS GEL-Melbourne OA) and conventional shoes in random order. Peak total forces were compared across conditions for: lateral heel, medial heel, lateral forefoot, and medial forefoot. Arch index, centre of pressure position and medial-lateral heel peak force ratio were also evaluated. Foot posture, foot mobility magnitude and navicular drop were separately added to the mixed linear model to investigate if these modified the effect of footwear on outcomes.

Results

Unloading shoes significantly increased lateral heel and lateral forefoot force (12.9 and 20.2% respectively, all P < 0.001), with concurrent decreases in the medial heel (8.9%, P = 0.001) and medial forefoot (9.9%, P = 0.005). Unloading shoes significantly shifted the centre of pressure anteriorly (4.7%, P < 0.001) and laterally (5.6%, P = 0.034), but did not affect the arch index (8.7%, P = 0.093). Foot posture, foot mobility magnitude and navicular drop did not moderate the effect of footwear on outcomes.

Conclusion

Compared to conventional shoes, unloading shoes caused a lateral shift in foot pressure and force patterns. Although these effects were not moderated by foot posture, FMM or navicular drop, variability in the individual increases in lateral heel force suggests participant characteristics other than foot posture may play a role.

Trial registration

ACTRN12613000851763. Registered 02 August 2013.

A generalisable methodology for stability assessment of walking aid users

To assist balance and mobility, older adults are often prescribed walking aids. Nevertheless, surprisingly their use has been associated with increased falls-risk. To address this finding we first need to characterise a person's stability while using a walking aid. Therefore, we present a generalisable method for the assessment of stability of walking frame (WF) users. Our method, for the first time, considers user and device as a combined system. We define the combined centre of pressure (CoP_system) of user and WF to be the point through which the resultant ground reaction force for all feet of both the WF and user acts if theresultant moment acts only around an axisperpendicular tothe ground plane. We also define the combined base of support (BoS_system) to be the convex polygon formed by the boundaries of the anatomical and WF feet in contact with the ground and interconnecting lines between them. To measure these parameters we have developed an instrumented WF with a load cell in each foot which we use together with pressure-sensing insoles and a camera system, the latter providing the relative position of the WF and anatomical feet. Software uses the resulting data to calculate the stability margin of the combined system, defined as the distance between CoP_system and the nearest edge of BoS_system. Our software also calculates the weight supported through the frame and when each foot (of user and/or frame) is on the floor. Finally, we present experimental work demonstrating the value of our approach.

Segmental kinematic analysis of planovalgus feet during walking in children with cerebral palsy

Pes planovalgus (flatfoot) is a common deformity among children with cerebral palsy. The Milwaukee Foot Model (MFM), a multi-segmental kinematic foot model, which uses radiography to align the underlying bony anatomy with reflective surface markers, was used to evaluate 20 pediatric participants (30feet) with planovalgus secondary to cerebral palsy prior to surgery. Three-dimensional kinematics of the tibia, hindfoot, forefoot, and hallux segments are reported and compared to an age-matched control set of typically-developing children. Most results were consistent with known characteristics of the deformity and showed decreased plantar flexion of the forefoot relative to hindfoot, increased forefoot abduction, and decreased ranges of motion during push-off in the planovalgus group. Interestingly, while forefoot characteristics were uniformly distributed in a common direction in the transverse plane, there was marked variability of forefoot and hindfoot coronal plane and hindfoot transverse plane positioning. The key finding of these data was the radiographic indexing of the MFM was able to show flat feet in cerebral palsy do not always demonstrate more hindfoot eversion than the typically-developing hindfoot. The coronal plane kinematics of the hindfoot show cases planovalgus feet with the hindfoot in inversion, eversion, and neutral. Along with other metrics, the MFM can be a valuable tool for monitoring kinematic deformity, facilitating clinical decision making, and providing a quantitative analysis of surgical effects on the planovalgus foot.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Foot Care in the Management of Juvenile Idiopathic Arthritis

OBJECTIVE

To create evidence-based guidelines evaluating foot care interventions for the management of juvenile idiopathic arthritis (JIA).

DATA SOURCES

An electronic literature search of the following databases from database inception to May 2015 was conducted: MEDLINE (Ovid), EMBASE (Ovid), Cochrane CENTRAL, and clinicaltrials.gov.

STUDY SELECTION

The Ottawa Panel selection criteria targeted studies that assessed foot care or foot orthotic interventions for the management of JIA in those aged 0 to ≤18 years. The Physiotherapy Evidence Database scale was used to evaluate study quality, of which only high-quality studies were included (score, ≥5). A total of 362 records were screened, resulting in 3 full-text articles and 1 additional citation containing supplementary information included for the analysis.

DATA EXTRACTION

Two reviewers independently extracted study data (intervention, comparator, outcome, time period, study design) from the included studies by using standardized data extraction forms. Directed by Cochrane Collaboration methodology, the statistical analysis produced figures and graphs representing the strength of intervention outcomes and their corresponding grades (A, B, C+, C, C-, D+, D, D-). Clinical significance was achieved when an improvement of ≥30% between the intervention and control groups was present, whereas P>.05 indicated statistical significance. An expert panel Delphi consensus (≥80%) was required for the endorsement of recommendations.

DATA SYNTHESIS

All included studies were of high quality and analyzed the effects of multidisciplinary foot care, customized foot orthotics, and shoe inserts for the management of JIA. Custom-made foot orthotics and prefabricated shoe inserts displayed the greatest improvement in pain intensity, activity limitation, foot pain, and disability reduction (grades A, C+).

CONCLUSIONS

The use of customized foot orthotics and prefabricated shoe inserts seems to be a good choice for managing foot pain and function in JIA.