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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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LaMarca AL, Krenn MJ, Kelso-Trass MA, MacDonald KC, Demeo CC, Bazarek SF, Brown JM. Selective Tibial Neurotomy Outcomes for Spastic Equinovarus Foot: Patient Expectations and Functional Assessment. Neurosurgery 2023; 93:1026-1035. [PMID: 37199494 DOI: 10.1227/neu.0000000000002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/27/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Spastic equinovarus foot (SEF) is a common dysfunctional foot posture after stroke that impairs balance and mobility. Selective tibial neurotomy (STN) is a simple but underutilized surgical option that can effectively address critical aspects of SEF and thereby provide enduring quality of life gains. There are few studies that examine both functional outcomes and patient satisfaction with this treatment option. OBJECTIVE To elucidate the patient goals that motivated their decision to undergo the procedure and compare subjective and objective changes in balance and functional mobility as a consequence of surgery. METHODS Thirteen patients with problematic SEF who had previously failed conservative measures were treated with STN. Preoperative and postoperative (on average 6 months) assessments evaluated gait quality and functional mobility. In addition, a custom survey was conducted to investigate patient perspectives on STN intervention. RESULTS The survey showed that participants who opted for STN were dissatisfied with their previous spasticity management. The most common preoperative expectation for STN treatment was to improve walking, followed by improving balance, brace comfort, pain, and tone. Postoperatively, participants rated the improvement in their expectations and were, on average, 71 on a 100-point scale, indicating high satisfaction. The gait quality, assessed with the Gait Intervention and Assessment Tool, improved significantly between preoperative and postoperative assessment (M = -4.1, P = .01) with a higher average difference in stance of -3.3 than in swing -0.5. Improvement in both gait endurance (M = 36 m, P = .01) and self-selected gait speed (M = .12 m/s, P = .03) was statistically significant. Finally, static balance (M = 5.0, P = .03) and dynamic balance (M = 3.5, P = .02) were also significantly improved. CONCLUSION STN improved gait quality and functional mobility and was associated with high satisfaction in patients with SEF.
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Affiliation(s)
- Amber L LaMarca
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Rehabilitation Sciences, MGH Institute of Health Professions, Boston , Massachusetts , USA
- Physical Therapy Department, Spaulding Rehabilitation Hospital, Boston , Massachusetts , USA
| | - Matthias J Krenn
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson , Mississippi , USA
- Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson , Mississippi , USA
| | - Molly A Kelso-Trass
- Physical Therapy Department, Wentworth-Douglass Hospital, Dover , New Hampshire , USA
| | - Kathryn C MacDonald
- Rehabilitation Sciences, MGH Institute of Health Professions, Boston , Massachusetts , USA
- Physical Therapy Department, Spaulding Rehabilitation Hospital, Boston , Massachusetts , USA
- Physical Therapy Department, Wentworth-Douglass Hospital, Dover , New Hampshire , USA
| | - Cristina C Demeo
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
| | - Stanley F Bazarek
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Harvard Medical School, Cambridge , Massachusetts , USA
- Brigham and Women's Hospital, Boston , Massachusetts , USA
| | - Justin M Brown
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Rehabilitation Sciences, MGH Institute of Health Professions, Boston , Massachusetts , USA
- Harvard Medical School, Cambridge , Massachusetts , USA
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Hara R, Rethlefsen SA, Wren TAL, Kay RM. Predictors of Changes in Pelvic Rotation after Surgery with or without Femoral Derotational Osteotomy in Ambulatory Children with Cerebral Palsy. Bioengineering (Basel) 2023; 10:1214. [PMID: 37892944 PMCID: PMC10604869 DOI: 10.3390/bioengineering10101214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Asymmetry of pelvic rotation affects function. However, predicting the post-operative changes in pelvic rotation is difficult as the root causes are complex and likely multifactorial. This retrospective study explored potential predictors of the changes in pelvic rotation after surgery with or without femoral derotational osteotomy (FDRO) in ambulatory children with cerebral palsy (CP). The change in the mean pelvic rotation angle during the gait cycle, pre- to post-operatively, was examined based on the type of surgery (with or without FDRO) and CP distribution (unilateral or bilateral involvement). In unilaterally involved patients, pelvic rotation changed towards normal with FDRO (p = 0.04), whereas patients who did not undergo FDRO showed a significant worsening of pelvic asymmetry (p = 0.02). In bilaterally involved patients, the changes in pelvic rotation did not differ based on FDRO (p = 0.84). Pelvic rotation corrected more with a greater pre-operative asymmetry (β = -0.21, SE = 0.10, p = 0.03). Sex, age at surgery, GMFCS level, and follow-up time did not impact the change in pelvic rotation. For children with hemiplegia, internal hip rotation might cause compensatory deviation in pelvic rotation, which could be improved with surgical correction of the hip. The predicted changes in pelvic rotation should be considered when planning surgery for children with CP.
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Affiliation(s)
- Reiko Hara
- Motion and Sports Analysis Laboratory, Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Susan A Rethlefsen
- Motion and Sports Analysis Laboratory, Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Tishya A L Wren
- Motion and Sports Analysis Laboratory, Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Robert M Kay
- Motion and Sports Analysis Laboratory, Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
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Grisch D, Stäuble M, Baumgartner S, van Hedel HJA, Meyer-Heim A, Dreher T, Krautwurst B. The Variable Influence of Orthotic Management on Hip and Pelvic Rotation in Children with Unilateral Neurogenic Equinus Deformity. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020307. [PMID: 36832437 PMCID: PMC9955931 DOI: 10.3390/children10020307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Equinus deformity with or without concomitant drop foot is a common finding in children with unilateral spastic cerebral palsy and spastic hemiplegia of other causes. Hypothetically, these deformities may lead to pelvic retraction and hip internal rotation during gait. Orthoses are used to reduce pes equinus during gait and to restore hindfoot first contact. OBJECTIVE We aimed to investigate whether the use of orthotic equinus correction reduces rotational hip and pelvic asymmetries. METHODS In a retrospective study, 34 children with unilateral spastic cerebral palsy or spastic hemiplegia of other causes underwent standardized instrumented 3D gait analysis with and without orthotic equinus management. We analyzed the differences in the torsional profile during barefoot walking and while wearing orthoses, as well as investigated the influence of ankle dorsiflexion and femoral anteversion on pelvic and hip kinematics and hip kinetics. RESULTS Wearing orthoses corrected pes equinus and pelvic internal rotation at the end of the stance phase and in the swing phase compared to barefoot walking. Hip rotation and the rotational moment did not significantly change with orthoses. Orthotic management or femoral anteversion did not correlate to pelvic and hip asymmetry. CONCLUSION The findings indicate that the correction of the equinus by using orthoses had a variable effect on the asymmetry of the hip and pelvis and internal rotation; both appear to have a multifactorial cause that is not primarily driven by the equinus component.
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Affiliation(s)
- Domenic Grisch
- Department of Pediatric Orthopedics, Neuroorthopedics and Traumatology, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Manuela Stäuble
- Department of Pediatric Orthopedics, Neuroorthopedics and Traumatology, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Sandra Baumgartner
- Swiss Children’s Rehab, University Children’s Hospital Zurich, 8910 Affoltern am Albis, Switzerland
| | - Hubertus J. A. van Hedel
- Swiss Children’s Rehab, University Children’s Hospital Zurich, 8910 Affoltern am Albis, Switzerland
| | - Andreas Meyer-Heim
- Swiss Children’s Rehab, University Children’s Hospital Zurich, 8910 Affoltern am Albis, Switzerland
| | - Thomas Dreher
- Department of Pediatric Orthopedics, Neuroorthopedics and Traumatology, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Pediatric Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zürich, Switzerland
- Correspondence: ; Tel.: +41-44-266-75-35
| | - Britta Krautwurst
- Department of Pediatric Orthopedics, Neuroorthopedics and Traumatology, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Pediatric Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zürich, Switzerland
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GMFCS Level-Specific Differences in Kinematics and Joint Moments of the Involved Side in Unilateral Cerebral Palsy. J Clin Med 2022; 11:jcm11092556. [PMID: 35566682 PMCID: PMC9100606 DOI: 10.3390/jcm11092556] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/02/2022] [Accepted: 04/24/2022] [Indexed: 01/16/2023] Open
Abstract
A variety of gait pathologies is seen in cerebral palsy. Movement patterns between different levels of functional impairment may differ. The objective of this work was the evaluation of Gross Motor Function Classification System (GMFCS) level-specific movement disorders. A total of 89 individuals with unilateral cerebral palsy and no history of prior treatment were included and classified according to their functional impairment. GMFCS level-specific differences, kinematics and joint moments, exclusively of the involved side, were analyzed for all planes for all lower limb joints, including pelvic and trunk movements. GMFCS level I and level II individuals most relevantly showed equinus/reduced dorsiflexion moments, knee flexion/reduced knee extension moments, reduced hip extension moments with pronounced flexion, internal hip rotation and reduced hip abduction. Anterior pelvic tilt, obliquity and retraction were found. Individuals with GMFCS level II were characterized by an additional pronounced reduction in all extensor moments, pronounced rotational malalignment and reduced hip abduction. The most striking characteristics of GMFCS level II were excessive anterior pelvic/trunk tilt and excessive trunk obliquity. Pronounced reduction in extensor moments and excessive trunk lean are distinguishing features of GMFCS level II. These patients would benefit particularly from surgical treatment restoring pelvic symmetry and improving hip abductor leverage. Future studies exploring GMFCS level-specific compensation of the sound limb and GMFCS level-specific malalignment are of interest.
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