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Huysmans SM, Senden R, Jacobs E, Willems PJ, Marcellis RG, Boogaart MVD, Meijer K, Willems PC. Gait alterations in patients with adult spinal deformity. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 17:100306. [PMID: 38293567 PMCID: PMC10825775 DOI: 10.1016/j.xnsj.2023.100306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 02/01/2024]
Abstract
Background Adult spinal deformity patients (ASD) experience altered spinal alignment affecting spatiotemporal parameters and joint kinematics. Differences in spinal deformity between patients with symptomatic idiopathic scoliosis (ID-ASD) and patients with "de novo" scoliosis (DN-ASD) may affect gait characteristics differently. This study aims to compare gait characteristics between ID-ASD, DN-ASD, and asymptomatic healthy matched controls. Methods In this observational case-control study, ID-ASD (n = 24) and DN-ASD (n = 26) patients visiting the out-patient spine clinic and scheduled for long-segment spinal fusion were included. Patients were matched, based on age, gender, leg length and BMI, with asymptomatic healthy controls. Gait was measured at comfortable walking speed on an instrumented treadmill with 3D motion capture system. Trunk, pelvic and lower extremities range of motion (ROM) and spatiotemporal parameters (SPT) are presented as median (first and thirds quartile). Independent t-test or Mann-Whitney U test was used to compare ID-ASD, DN-ASD and controls. Statistical Parametric Mapping (independent t-test) was used to compare 3D joint kinematics. Results DN-ASD patients walk with increased anterior trunk tilt during the whole gait cycle compared with ID-ASD patients and controls. ID-ASD walk with decreased trunk lateroflexion compared with DN-ASD and controls. DN-ASD showed decreased pelvic obliquity and -rotation, increased knee flexion, and decreased ankle plantar flexion. ID-ASD and DN-ASD displayed decreased trunk, pelvic and lower extremity ROM compared with controls, but increased pelvic tilt ROM. ID-ASD patients walked with comparable SPT to controls, whereas DN-ASD patients walked significantly slower with corresponding changes in SPT and wider steps. Conclusions DN-ASD patients exhibit distinct alterations in SPT and kinematic gait characteristics compared with ID-ASD and controls. These alterations seem to be predominantly influenced by sagittal spinal malalignment and kinematic findings in ASD patients should not be generalized as such, but always be interpreted with consideration for the nature of the ASD.
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Affiliation(s)
- Stephanie M.D. Huysmans
- Department of Orthopedic Surgery and Research School CAPHRI (Care and Public Health Research Institute), Maastricht University Medical Center+ (MUMC+), Maastricht, the Netherlands
| | - Rachel Senden
- Department of Physiotherapy, Maastricht University Medical Center+ (MUMC+), Maastricht, the Netherlands
| | - Eva Jacobs
- Department of Orthopedic Surgery and Research School CAPHRI (Care and Public Health Research Institute), Maastricht University Medical Center+ (MUMC+), Maastricht, the Netherlands
| | - Paul J.B. Willems
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism (MUMC+), the Netherlands
| | - Rik G.J. Marcellis
- Department of Physiotherapy, Maastricht University Medical Center+ (MUMC+), Maastricht, the Netherlands
| | - Mark van den Boogaart
- Department of Orthopedic Surgery and Research School CAPHRI (Care and Public Health Research Institute), Maastricht University Medical Center+ (MUMC+), Maastricht, the Netherlands
| | - Kenneth Meijer
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism (MUMC+), the Netherlands
| | - Paul C. Willems
- Department of Orthopedic Surgery and Research School CAPHRI (Care and Public Health Research Institute), Maastricht University Medical Center+ (MUMC+), Maastricht, the Netherlands
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Sweetman H, Rahman M, Vedantam A, Satkunendrarajah K. Subclinical respiratory dysfunction and impaired ventilatory adaptation in degenerative cervical myelopathy. Exp Neurol 2024; 371:114600. [PMID: 37907124 DOI: 10.1016/j.expneurol.2023.114600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/02/2023]
Abstract
Degenerative cervical myelopathy (DCM) is a debilitating neurological condition characterized by chronic compression of the cervical spinal cord leading to impaired upper and lower limb function. Despite damage to areas of the cervical spinal cord that house the respiratory network, respiratory dysfunction is not a common symptom of DCM. However, DCM may be associated with respiratory dysfunction, and this can affect the ventilatory response to respiratory challenges during emergence from anesthesia, exercise, or pulmonary disease. Surgical spinal cord decompression, which is the primary treatment for DCM, leads to improved sensorimotor function in DCM; yet its impact on respiratory function is unknown. Here, using a clinically relevant model of DCM, we evaluate respiratory function during disease progression and assess adaptive ventilation to hypercapnic challenge before and after surgical intervention. We show that despite significant and progressive forelimb and locomotor deficits, there was no significant decline in eupneic ventilation from the early to late phases of spinal cord compression. Additionally, for the first time, we demonstrate that despite normal ventilation under resting conditions, DCM impairs acute adaptive ventilatory ability in response to hypercapnia. Remarkably, akin to DCM patients, surgical decompression treatment improved sensorimotor function in a subset of mice. In contrast, none of the mice that underwent surgical decompression recovered their ability to respond to hypercapnic ventilatory challenge. These findings underscore the impact of chronic spinal cord compression on respiratory function, highlighting the challenges associated with ventilatory response to respiratory challenges in individuals with DCM. This research highlights the impact of cervical spinal cord compression on respiratory dysfunction in DCM, as well as the persistence of adaptive ventilatory dysfunction after surgical spinal cord decompression. These results indicate the need for additional interventions to enhance recovery of respiratory function after surgery for DCM.
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Affiliation(s)
- Hannah Sweetman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
| | - Mahmudur Rahman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aditya Vedantam
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
| | - Kajana Satkunendrarajah
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA; Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Guo C, Liang Y, Xu S, Zheng B, Liu H. Lasso Analysis of Gait Characteristics and Correlation with Spinopelvic Parameters in Patients with Degenerative Lumbar Scoliosis. J Pers Med 2023; 13:1576. [PMID: 38003891 PMCID: PMC10671873 DOI: 10.3390/jpm13111576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023] Open
Abstract
PURPOSE This study quantifies the gait characteristics of patients with degenerative lumbar scoliosis (DLS) and patients with simple lumbar spinal stenosis (LSS) by means of a three-dimensional gait analysis system, aiming to determine the image of spinal deformity on gait and the correlation between spinal-pelvic parameters and gait characteristics in patients with DLS to assist clinical work. METHODS From June 2020 to December 2021, a total of 50 subjects were enrolled in this study, of whom 20 patients with DLS served as the case group and 30 middle-aged and elderly patients with LSS were selected as the control group according to the general conditions (sex, age, and BMI) of the case group. Spinal-pelvic parameters were measured by full-length frontal and lateral spine films one week before surgery, and kinematics were recorded on the same day using a gait analysis system. RESULTS Compared to the control group, DLS patients exhibited significantly reduced velocity and cadence; gait variability and symmetry of both lower limbs were notably better in the LSS group than in the DLS group; joint ROM (range of motion) across multiple dimensions was also lower in the DLS group; and correlation analysis revealed that patients with a larger Cobb angle, T1PA, and higher CSVA tended to walk more slowly, and those with a larger PI, PT, and LL usually had smaller stride lengths. The greater the PI-SS mismatch, the longer the patient stayed in the support phase. Furthermore, a larger Cobb angle correlated with worse coronal hip mobility. CONCLUSIONS DLS patients demonstrate distinctive gait abnormalities and reduced hip mobility compared to LSS patients. Significant correlations between crucial spinopelvic parameters and these gait changes underline their potential influence on gait disturbances in DLS. Our study identifies a Cobb angle cut-off of 16.1 as a key predictor for gait abnormalities. These insights can guide personalized treatment and intervention strategies, ultimately improving the quality of life for DLS patients.
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Affiliation(s)
- Chen Guo
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Yan Liang
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Shuai Xu
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Bin Zheng
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Haiying Liu
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, Beijing 100044, China
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Hachiya K, Kawabata S, Michikawa T, Nagai S, Takeda H, Ikeda D, Kaneko S, Fujita N. Severity of locomotive syndrome in surgical cervical spondylotic myelopathy patients: a cross-sectional study. FUJITA MEDICAL JOURNAL 2023; 9:246-252. [PMID: 37554936 PMCID: PMC10405894 DOI: 10.20407/fmj.2022-035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/20/2022] [Indexed: 08/10/2023]
Abstract
OBJECTIVES Although cervical spondylotic myelopathy (CSM) has a marked impact on locomotive function, few studies have evaluated this relationship in terms of locomotive syndrome. Thus, we assessed (i) the stages of locomotive syndrome in preoperative CSM patients using the 25-question geriatric locomotive function scale (GLFS-25), (ii) the correlation between GLFS-25 scores and the Japanese orthopaedic association (JOA) scores or the JOA cervical myelopathy evaluation questionnaire (JOACMEQ) scores, and (iii) the factors associated with stage 3 locomotive syndrome in preoperative CSM patients. METHODS We used clinical data from 107 patients scheduled for cervical spinal surgery for CSM. Data were collected prior to surgery, and included age, gender, body mass index, medical history, JOA score, and JOACMEQ and GLFS-25 scores. RESULTS Of the included CSM patients, 93.5% were diagnosed with locomotive syndrome, of whom 77.6% were stage 3 according to GLFS-25 evaluation. For the correlation between GLFS-25 and JOA or JOACMEQ, the upper and lower extremity function scores of JOACMEQ and the JOA were strongly inversely correlated with the GLFS-25 score. Finally, multivariate analysis suggested that severe lower extremity status in the JOACMEQ was significantly associated with stage 3 locomotive syndrome in preoperative CSM patients. CONCLUSIONS Using the GLFS-25, we found that lower extremity status had the strongest association with stage 3 locomotive syndrome in preoperative CSM patients. These findings are useful for preventing CSM patients from requiring future nursing care.
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Affiliation(s)
- Kurenai Hachiya
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Soya Kawabata
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Takehiro Michikawa
- Department of Environmental and Occupational Health, School of Medicine, Toho University, Ota, Tokyo, Japan
| | - Sota Nagai
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Hiroki Takeda
- Department of Spine and Spinal Cord Surgery, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Daiki Ikeda
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Shinjiro Kaneko
- Department of Spine and Spinal Cord Surgery, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Nobuyuki Fujita
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
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Khan Z, Jiao X, Hu T, Shao Q, Sun X, Zhao X, Gu D. Investigation of gait, balance and lower extremity muscle activity during walking in patients with cervical spondylotic myelopathy using wearable sensors. Spine J 2023:S1529-9430(23)00106-7. [PMID: 36934793 DOI: 10.1016/j.spinee.2023.03.004] [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: 10/31/2022] [Revised: 02/28/2023] [Accepted: 03/10/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND CONTEXT Cervical spondylotic myelopathy (CSM) is a degenerative disease caused by cervical cord compression and can lead to the significant impairment of motor function including gait and balance disturbances and changes in lower extremity muscle activity. PURPOSE This study aimed to characterize gait, balance and lower extremity muscle activity in patients with CSM compared to age-matched healthy controls (HCs) using wearable sensors in the clinical setting. STUDY DESIGN Non-Randomized, prospective cohort study. PATIENT SAMPLE 10 CSM patients and 10 age-matched HCs were recruited for this study. OUTCOME MEASURES Gait and balance function parameters contained spatial temporal parameters, step regularity (SR1), stride regularity (SR2) and harmonic ratio (HR). EMG muscle activity parameters included time to peak and peak value during loading, stance, and swing phase. METHODS In this study, parameters of gait and balance function were extracted using triaxial accelerometer attached to the spinous processes of Lumbar 5 while participants performed an overground walking at a self-preferred speed. Moreover, muscular activity was simultaneously recorded via sEMG sensors attached to tibialis anterior (TA), rectus femoris (RF), bicep femoris (BF) and gastrocnemius lateral (GL). Independent sample t-test was used to find the differences between CSM patients and HCs. RESULTS Gait analysis showed cadence, step length and walking speed were statistically significantly lower in CSM patients than HCs. Stride time was significantly higher for CSM patients in comparison to HCs. Lower root mean square ratio (RMSR) of acceleration in the mediolateral (ML) direction, HR in the anteroposterior (AP) direction, SR1 in the AP direction and SR2 in all three directions were observed in CSM patients. For muscle activity analysis, EMG RMS for TA and RF during loading phase and RMS for GL during midstance phase was significantly lower for CSM patients, while significantly higher value was observed for RF RMS during midstance phase and GL RMS during swing phase in CSM patients. CONCLUSION Our pilot study shows that wearable sensors are able to detect the changes of gait, balance and lower extremity muscle activities of CSM patients in the clinical setting. This pilot study sets the stage for future researches on the diagnosis and monitor progression of CSM disease using wearable technology.
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Affiliation(s)
- Zawar Khan
- Shanghai Key Laboratory of Orthopaedic Implants and Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, Shanghai 200011, China; School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200030, China; Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai 200030, China
| | - Xin Jiao
- Shanghai Key Laboratory of Orthopaedic Implants and Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, Shanghai 200011, China; School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200030, China; Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai 200030, China
| | - Tianyi Hu
- Shanghai Key Laboratory of Orthopaedic Implants and Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, Shanghai 200011, China; School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200030, China; Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai 200030, China
| | - Qineng Shao
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200030, China; Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai 200030, China
| | - Xin Sun
- Shanghai Key Laboratory of Orthopaedic Implants and Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, Shanghai 200011, China
| | - Xin Zhao
- Shanghai Key Laboratory of Orthopaedic Implants and Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, Shanghai 200011, China.
| | - Dongyun Gu
- Shanghai Key Laboratory of Orthopaedic Implants and Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, Shanghai 200011, China; School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200030, China; Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai 200030, China.
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Analysis of Spastic Gait in Patients With Cervical Myelopathy Using the Timed Up and Go Test With a Laser Range Sensor. Spine (Phila Pa 1976) 2022; 47:892-898. [PMID: 34802028 DOI: 10.1097/brs.0000000000004284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVE This study aimed to objectively evaluate spastic gait and reveal its novel characteristics via analysis of gait in patients with cervical myelopathy (CM) using the Timed Up and Go (TUG) test with a laser range sensor. SUMMARY OF BACKGROUND DATA Among patients with CM, spastic gait is a common diagnostic symptom; thus, objective assessments of spastic gait would be useful for the diagnosis of CM and recognition of disease status. Although spastic gait has been objectively evaluated in previous studies, the methods employed in those studies are not suitable for clinical settings. METHODS In total, 37 and 24 participants were recruited for a control group and CM group, respectively. CM was diagnosed by spine surgeons. We developed a laser TUG test, in which the position and velocity of both the legs were captured. The parameter values for both groups were statistically compared, and odds ratios were calculated using logistic regression analyses. RESULTS The total TUG-test time, time to stand up, time to first step, number of steps, and trajectory error for the CM group were significantly higher than those for the control group, whereas the average velocity and average stride length for the CM group were significantly lower than those for the control group. There was a significant independent association between the total TUG-test time and CM. The optimal cutoff point of the total test time for CM risk was approximately 9 seconds. CONCLUSION Through the use of the laser TUG test, we were able to identify characteristics of spastic gait, which leads to difficulty in standing and taking the first step, wobbling while walking, and an increased risk of falling. We found that the risk of CM was higher if the individual took longer than 9 seconds to complete the TUG test.Level of Evidence: 4.
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Quantitative Romberg using a force plate: an objective measure for cervical myelopathy. Spine J 2022; 22:535-541. [PMID: 34648937 DOI: 10.1016/j.spinee.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgical decision making for cervical spondylotic myelopathy (CSM) relies on evaluation of symptoms and physical examination. The Romberg test is a clinical exam used to identify balance issues with CSM. However, the Romberg test has a subjective interpretation and has a binary (positive or negative) result. PURPOSE This study aims to compare force plate pressure readings during a standard Romberg test in patients with CSM to age-matched normal healthy volunteers. STUDY DESIGN/SETTING Prospective cross sectional observational comparative cohort from a single multi-surgeon spine center. PATIENT SAMPLE Patients who were clinically diagnosed with CSM were compared to age-matched healthy volunteers without a clinical history of spine pathology. OUTCOME MEASURES Quantitative Romberg Force Plate Measurements METHODS: Patients with CSM requiring surgery and healthy normal volunteers were asked to perform the Romberg test while on a force plate measuring the center of pressure (COP): standing up straight with arms extended for 30 seconds with eyes open, followed by 30 seconds with eyes closed. The change for total sway area, sway frequency and sway speed with eyes closed and eyes open were calculated and compared between patients with CSM and healthy volunteers. RESULTS Thirty-four CSM patients were age-matched to 34 healthy volunteers. There was a larger change in quantitative Romberg measurements with eyes open versus eyes closed in CSM patients compared to normal volunteers for maximum lateral movement (10.79 cm vs. 0.94 cm, p=.003), maximum anterior-posterior movement (15.06 cm vs. 10.00 cm p=.201), total lateral CoP movement (89.82cm vs. 18.71cm, p=.007), total AP CoP movement (154.68 cm vs. 87.47 cm, p=.601), total CoP trace movement (199.79 cm vs. 88.44 cm, p=.014), sway area (284.74 cm2 vs. 57.76 cm2, p=.006), and average speed (7.00 cm/s vs. 2.91 cm/s, p=.006). DISCUSSION Poor standing balance can be quantified in patients with CSM. Quantifying standing balance in patients with CSM shows significantly worse objective measures than age-matched healthy volunteers. The Romberg test on a force plate may help diagnose and evaluate patients with CSM, guide patient management and potentially grade the severity of spinal pathology. Further studies are needed to determine its utility in monitoring disease progression and measure treatment effectiveness.
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Tetreault L, Garwood P, Gharooni AA, Touzet AY, Nanna-Lohkamp L, Martin A, Wilson J, Harrop JS, Guest J, Kwon BK, Milligan J, Arizala AM, Riew KD, Fehlings MG, Kotter MRN, Kalsi-Ryan S, Davies BM. Improving Assessment of Disease Severity and Strategies for Monitoring Progression in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 4]. Global Spine J 2022; 12:64S-77S. [PMID: 34971524 PMCID: PMC8859700 DOI: 10.1177/21925682211063854] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
STUDY DESIGN Narrative Review. OBJECTIVE To (i) discuss why assessment and monitoring of disease progression is critical in Degenerative cervical myelopathy (DCM); (ii) outline the important features of an ideal assessment tool and (iii) discuss current and novel strategies for detecting subtle deterioration in DCM. METHODS Literature review. RESULTS Degenerative cervical myelopathy is an overarching term used to describe progressive injury to the cervical spinal cord by age-related changes of the spinal axis. Based on a study by Smith et al (2020), the prevalence of DCM is approximately 2.3% and is expected to rise as the global population ages. Given the global impact of this disease, it is essential to address important knowledge gaps and prioritize areas for future investigation. As part of the AO Spine RECODE-DCM (Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy) project, a priority setting partnership was initiated to increase research efficiency by identifying the top ten research priorities for DCM. One of the top ten priorities for future DCM research was: What assessment tools can be used to evaluate functional impairment, disability and quality of life in people with DCM? What instruments, tools or methods can be used or developed to monitor people with DCM for disease progression or improvement either before or after surgical treatment? CONCLUSIONS With the increasing prevalence of DCM, effective surveillance of this population will require both the implementation of a monitoring framework as well as the development of new assessment tools.
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Affiliation(s)
- Lindsay Tetreault
- Department of Neurology, Langone Health, Graduate Medical Education, New York University, New York, NY, USA
| | - Philip Garwood
- Graduate Medical Education, Internal Medicine, University of Toronto, Toronto, ON, Canada
| | - Aref-Ali Gharooni
- Neurosurgery Unit, Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | | | - Laura Nanna-Lohkamp
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Allan Martin
- Department of Neurosurgery, University of California Davis, Sacramento, CA, USA
| | - Jefferson Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - James Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Brian K. Kwon
- Vancouver Spine Surgery Institute, Department of Orthopedics, The University of British Columbia, Vancouver, BC, Canada
| | - James Milligan
- McMaster University Department of Family Medicine, Hamilton, ON, Canada
| | - Alberto Martinez Arizala
- The Miami Project to Cure Paralysis, The Miller School of Medicine University of Miami, Miami, FL, USA
| | - K. Daniel Riew
- Department of Orthopaedics, The Och Spine Hospital at New York-Presbyterian, Columbia University Medical Center, New York, NY, USA
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Sukhvinder Kalsi-Ryan
- KITE Research Institute, University Health Network, Toronto, ON, Canada
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada
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Hirai T, Otani K, Sekiguchi M, Kikuchi SI, Konno SI. Epidemiological study of cervical cord compression and its clinical symptoms in community-dwelling residents. PLoS One 2021; 16:e0256732. [PMID: 34449818 PMCID: PMC8396744 DOI: 10.1371/journal.pone.0256732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 08/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Degenerative compressive myelopathy (DCM) is caused by cervical cord compression. The relationship between the magnitude and clinical findings of cervical cord compression has been described in the literature, but the details remain unclear. This study aimed to clarify the relationship between the magnitude and clinical symptoms of cervical cord compression in community-dwelling residents. METHODS The present study included 532 subjects. The subjective symptoms and the objective findings of one board-certified spine surgeon were assessed. The subjective symptoms were upper extremity pain and numbness, clumsy hand, fall in the past 1 year, and subjective gait disturbance. The objective findings were: Hoffmann, Trömner, and Wartenberg signs; Babinski's and Chaddock's signs; hyperreflexia of the patellar tendon and Achilles tendon reflexes; ankle clonus; Romberg and modified Romberg tests; grip and release test; finger escape sign; and grip strength. Using midsagittal T2-weighted magnetic resonance imaging, the anterior-posterior (AP) diameters (mm) of the spinal cord at the C2 midvertebral body level (DC2) and at each intervertebral disc level from C2/3 to C7/T1 (DC2/3-C7/T1) were measured. The spinal cord compression ratio (R) for each intervertebral disc level was defined and calculated as DC2/3-C7/T1 divided by DC2. The lowest R (LR) along C2/3 to C7/T1 of each individual was divided into 3 grades by the tertile method. The relationship between LR and clinical symptoms was investigated by trend analysis. RESULTS The prevalence of subjective gait disturbance increased significantly with the severity of spinal cord compression (p = 0.002812), whereas the other clinical symptoms were not significantly related with the severity of spinal cord compression. CONCLUSIONS The magnitude of cervical cord compression had no relationship with any of the neurologic findings. However, subjective gait disturbance might be a better indicator of the possibility of early stage cervical cord compression.
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Affiliation(s)
- Toru Hirai
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Koji Otani
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Miho Sekiguchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shin-ichi Kikuchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shin-ichi Konno
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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Diagnostic usefulness of 10-step tandem gait test for the patient with degenerative cervical myelopathy. Sci Rep 2021; 11:17212. [PMID: 34446786 PMCID: PMC8390502 DOI: 10.1038/s41598-021-96725-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 08/10/2021] [Indexed: 01/28/2023] Open
Abstract
Tandem gait is considered one of the most useful screening tools for gait impairment. The aim of this study is to evaluate diagnostic usefulness of 10-step tandem gait test for the patients with degenerative cervical myelopathy (DCM). Sixty-two DCM patients were compared to 55 persons without gait abnormalities as control. We counted the number of consecutive steps and graded into five according the number of steps and stability. Five grades of tandem gait were investigated for association with clinical parameters including qualitative Japanese orthopedic association (JOA) sub-score for lower extremities and Nurick scale and quantitative balance and gait assessments. The number of tandem steps were reduced and the grades of tandem gait were differently distributed in the DCM patients compared to controls (steps, 7.1 ± 3.6 versus 9.9 ± 0.4, p < 0.001; grades of 0/1/2/3/4/5, 1/13/14/15/19 versus 0/0/2/15/38, p < 0.001 in patients with DCM and control respectively). Patients with DCM showed more unstable balance and abnormal gait features including slower velocity, shorter strides, wider bases with increased stance phase of a gait cycle compared to the control group. The grades of tandem gait were correlated with JOA sub-score (r = 0.553, p < 0.001) and the Nurick scale (r = - 0.652, p < 0.001) as well as both balance and gait parameters. In DCM patients, tandem gait was impaired and correlated with severity of gait abnormality. The authors believe that 10-step tandem gait test is an objective and useful screening test for evaluating gait disturbance in patients with DCM.
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Haddas R, Boah A, Block A. Fear-avoidance and Patients' Reported Outcomes are Strongly Correlated With Biomechanical Gait Parameters in Cervical Spondylotic Myelopathy Patients. Clin Spine Surg 2021; 34:E289-E294. [PMID: 33290329 DOI: 10.1097/bsd.0000000000001111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 11/07/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a prospective cohort study. OBJECTIVE The aim was to explores whether fear-avoidance is associated with altered gait patterns in cervical spinal myelopathy (CSM) patients. SUMMARY OF BACKGROUND DATA Fear-avoidance is associated with activity restriction and emotional distress in chronic pain patients and with poorer spine surgery outcomes. In adults with spinal deformity, fear and avoidance correlates with gait pattern disruptions. Patients having CSM also display distorted gait. METHODS Ninety CSM patients completed the Tampa Scale for Kinesiophobia (TSK) questionnaire, and the Fear-avoidance Beliefs Questionnaire (FABQ). Each patient performed a series of gait trials. Pearson's product correlation analysis was used to determine the relationship between the self-reported fear of movement measures and the objective gait biomechanical data. RESULTS The TSK total score was correlated with walking speed ( P =0.003), cadence ( P =0.012), stride ( P =0.010) and step ( P =0.036) time, and stride ( P =0.018) and step ( P =0.035) length. The FABQ physical dimension was correlated with walking speed ( P <0.001), cadence ( P <0.001), stride ( P <0.001) and step ( P =0.006) time, stride ( P <0.001) and step ( P <0.001) length, and gait deviation index ( P <0.001). The FABQ work dimension was correlated with walking speed ( P =0.001), cadence ( P =0.001), stride ( P =0.001) and step ( P =0.008) time, and stride ( P =0.014) and step ( P =0.002) length. CONCLUSIONS These results provide a framework for further investigation of the relationship between psychosocial factors and objectively measured function in patients with CSM. This study demonstrates a strong correlation between fear and avoidance of movement, as measured with the TSK and FABQ and multiple biomechanical gait parameters, as measured with gait analysis. The current results may imply that fear and avoidance may compound and worsen functional deficits arising from CSM, and strongly suggest that fear and avoidance beliefs should be included as a component of presurgical diagnostic process for CSM patients.
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Affiliation(s)
- Ram Haddas
- Research Department, Texas Back Institute, Plano
| | - Akwasi Boah
- Research Department, Texas Back Institute, Denton, TX
| | - Andrew Block
- Research Department, Texas Back Institute, Plano
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Kadanka Z, Kadanka Z, Skutil T, Vlckova E, Bednarik J. Walk and Run Test in Patients with Degenerative Compression of the Cervical Spinal Cord. J Clin Med 2021; 10:jcm10050927. [PMID: 33804299 PMCID: PMC7957594 DOI: 10.3390/jcm10050927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 01/26/2023] Open
Abstract
Impaired gait is one of the cardinal symptoms of degenerative cervical myelopathy (DCM) and frequently its initial presentation. Quantitative gait analysis is therefore a promising objective tool in the disclosure of early cervical cord impairment in patients with degenerative cervical compression. The aim of this cross-sectional observational cohort study was to verify whether an objective and easily-used walk and run test is capable of detecting early gait impairment in a practical proportion of non-myelopathic degenerative cervical cord compression (NMDCC) patients and of revealing any correlation with severity of disability in DCM. The study group consisted of 45 DCM patients (median age 58 years), 126 NMDCC subjects (59 years), and 100 healthy controls (HC) (55.5 years), all of whom performed a standardized 10-m walk and run test. Walking/running time/velocity, number of steps and cadence of walking/running were recorded; analysis disclosed abnormalities in 66.7% of NMDCC subjects. The DCM group exhibited significantly more pronounced abnormalities in all walk/run parameters when compared with the NMDCC group. These were apparent in 84.4% of the DCM group and correlated closely with disability as quantified by the modified Japanese Orthopaedic Association scale. A standardized 10-m walk/run test has the capacity to disclose locomotion abnormalities in NMDCC subjects who lack other clear myelopathic signs and may provide a means of classifying DCM patients according to their degree of disability.
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Affiliation(s)
- Zdenek Kadanka
- Department of Neurology, University Hospital, 625 00 Brno, Czech Republic; (Z.K.S.); (E.V.); (J.B.)
- Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic;
- Correspondence: ; Tel.: +420-532232354
| | - Zdenek Kadanka
- Department of Neurology, University Hospital, 625 00 Brno, Czech Republic; (Z.K.S.); (E.V.); (J.B.)
- Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic;
| | - Tomas Skutil
- Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic;
| | - Eva Vlckova
- Department of Neurology, University Hospital, 625 00 Brno, Czech Republic; (Z.K.S.); (E.V.); (J.B.)
- Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic;
- Central European Institute of Technology, Masaryk University, 625 00 Brno, Czech Republic
| | - Josef Bednarik
- Department of Neurology, University Hospital, 625 00 Brno, Czech Republic; (Z.K.S.); (E.V.); (J.B.)
- Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic;
- Central European Institute of Technology, Masaryk University, 625 00 Brno, Czech Republic
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Ver MLP, Gum JL, Glassman SD, Carreon LY. Assessment of standing balance in normal versus cervical spondylotic myelopathy patients. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2020; 3:100023. [PMID: 35141591 PMCID: PMC8820038 DOI: 10.1016/j.xnsj.2020.100023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/30/2020] [Accepted: 08/11/2020] [Indexed: 11/21/2022]
Abstract
Background The Romberg test is used to identify balance issues in patients with Cervical Spondylotic Myelopathy (CSM), but has subjective interpretation. The purpose of this study is to evaluate force plate pressure readings during a Romberg test to quantify postural control. Methods Quantitative Romberg force plate readings with eyes open and closed in patients with CSM were obtained and changes in balance measurements were compared to a normal population (N = 28, mean age 39 ± 7 years). Results We identified 30 CSM patients with a mean age of 58 ± 10 years. Majority of patients presented with pain (90%) and neurologic symptoms (83%). Cord compression on imaging was identified in 90%. Mean eyes closed Romberg measurements were larger compared to eyes open measurements in CSM patients (p < 0.01). There was a larger change in Romberg (∆R) measurements in CSM compared to normals for total sway area (TSA, 14.18 vs 0.02 cm2, p < 0.001) and average speed (AS, 2.07 vs 0.23 cm/s, p < 0.001). The presence of long tract signs produced larger ∆R (TSA, 15.35 vs 0.02 cm2, p = 0.003; AS, 2.21 vs 0.23 cm/s, p = 0.001), and those with identified cord compression on imaging also had larger ∆R (TSA, 15.1 vs 0.02 cm2, p < 0.001; AS, 2.17 vs 0.23 cm/s, p < 0.001). Conclusions Standing balance can be quantified in patients with CSM and is worse when compared to a normal population. Long tract signs and cord compression in imaging translates to worse balance in myelopathic patients. The use of quantitative Romberg measurements help evaluate balance in CSM.
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A Diagnostic Approach to Myelopathy Based on Prognostic Factors in Patients With Lower Extremity Symptoms. Spine (Phila Pa 1976) 2020; 45:E792-E798. [PMID: 32044809 DOI: 10.1097/brs.0000000000003411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case-control study. OBJECTIVE We aimed to identify predictors for latent myelopathy and to develop a diagnostic protocol based on these factors. SUMMARY OF BACKGROUND DATA There is no diagnostic protocol for latent myelopathy to avoid misdiagnosis in patients complaining only of lower extremity symptoms. METHODS This case-control study identified 791 patients discussed at conferences from April 2006 to August 2012. Overall, 460 patients complaining only of lower extremity symptoms and who underwent spine surgery were included as participants; 54 underwent surgery involving the cervical and thoracic vertebrae and were assigned to the cervical-thoracic group (C-T group); 406 underwent lumbar surgery and were assigned to the lumbar group (L group). RESULTS By univariate analysis, age ≥67 years, patellar tendon (PT) hyperreflexia, Achilles tendon (AT) hyperreflexia, spastic gait, and gait inability were more common in the C-T group than in the L group. By multivariate analysis, age ≥67 years (OR, 8; P = 0.001), AT hyperreflexia (OR, 20.5; P < 0.001), spastic gait (OR, 225; P < 0.001), and gait inability (OR, 64; P < 0.001) were significant predictive factors. In patients with age ≥67 years, PT hyperreflexia, and/or AT hyperreflexia, the sensitivity for myelopathy diagnosis was 98%. In patients with spastic gait or gait inability, the specificity of myelopathy diagnosis was 96%. CONCLUSIONS We analyzed factors that predict latent myelopathy in patients complaining only of lower extremity symptoms. We believe a diagnostic protocol based on the predictors shown in this study would contribute to the accurate diagnosis of latent myelopathy. LEVEL OF EVIDENCE 4.
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Mar D, Lieberman I, Haddas R. The Gait Deviation Index as an indicator of gait abnormality among degenerative spinal pathologies. 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 2019; 29:2591-2599. [PMID: 31838597 DOI: 10.1007/s00586-019-06252-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/26/2019] [Accepted: 12/09/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The Gait Deviation Index (GDI) is a composite measure of gait abnormality derived from lower-limb joint range-of-motion which is increasingly being reported for clinical gait analysis among neurologic and orthopedic patients. A GDI score of 100 is representative of healthy individuals and decreasing scores represent a greater abnormality. Preliminary data is needed to help assess the utility of GDI as a measure of compromised gait among spine patients and to provide reference values for commonly treated pathologies. METHODS GDI scores were obtained from healthy adults and four symptomatic degeneration groups: cervical spondylotic myelopathy (CSM), adult degenerative scoliosis (ADS), and single-level lumbar degeneration (LD). Clinical gait analysis was done using a three-dimensional motion tracking system. Evaluations were done 1 week prior to surgical intervention for degeneration groups. Two-sample t-tests were used to compare degenerative cohorts to healthy controls and for inter-cohort comparisons. Pearson correlations were used to test for significant relationships between GDI and walking speed. RESULTS Degenerative cohorts all showed significantly lower (worse) GDI scores compared to healthy (all p < 0.001). CSM patients showed the best GDI scores with an average of 90, and LD patients showed the worst GDI scores with an average of 86. Worsening GDI significantly correlated with decreased walking speed among ADS patients. CONCLUSION Composite metrics like GDI provide a tempting means to summarize nuanced and complex gait characteristics into a single, comparable value among cohorts. The results of this study provide preliminary GDI scores for common degenerative spine pathologies. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Damon Mar
- Texas Back Institute, 6020 West Parker Road, Plano, TX, 75093, USA
| | - Isador Lieberman
- Texas Back Institute, 6020 West Parker Road, Plano, TX, 75093, USA
| | - Ram Haddas
- Texas Back Institute, 6020 West Parker Road, Plano, TX, 75093, USA.
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Takamatsu Y, Matsuda N, Aiba I. The combination of short-step and wide-based gait is a gait characteristic in progressive supranuclear palsy: a retrospective, cross-sectional study. Eur Geriatr Med 2019; 10:809-815. [PMID: 34652693 DOI: 10.1007/s41999-019-00211-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 05/29/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Like Parkinson's disease (PD), gait disturbance is a major problem in progressive supranuclear palsy (PSP). Despite limited studies investigating the gait characteristics, we hypothesize that they differ from PD owing to the involvement of different brain lesions. Hence, this study aims to investigate the gait characteristics in patients with PSP by comparing with healthy older adults and patients with PD. METHODS We identified 27 PSP patients, 25 PD patients, and 25 neurologically healthy older persons. Using a device that detected the distribution of foot pressure during walking, we analyzed gait variables and measured the walking speed (cm/s), cadence (steps/min), step length (cm), step width (cm), foot angle (°), and gait cycle time (s). Additionally, we calculated the coefficient of variation (CV, %) on walking speed and cadence and analyzed the gait characteristics by the PSP subtypes. RESULTS In PSP and PD, the walking speed was slower and the step length was shorter than healthy controls. The CV of cadence in PSP was higher than healthy controls and PD. In PSP, the step width and foot angle were higher than healthy controls and PD. The gait cycle time was longer in PSP and PD than healthy controls. PSP with progressive freezing gait tended to display a faster walking speed. Furthermore, PSP with parkinsonism-resembling idiopathic PD tended to exhibit the larger step width and foot angle compared with PSP-Richardson's syndrome. CONCLUSION This study suggests that the gait of PSP was unstable with parkinsonism and wide-based, which might be similar to combining features of PD and cerebellar disorders.
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Affiliation(s)
- Yasuyuki Takamatsu
- Department of Rehabilitation, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi, 465-8620, Japan.
- Department of Rehabilitation Science, Faculty of Health Sciences, Hokkaido University, Kita 12 Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-0812, Japan.
| | - Naomi Matsuda
- Department of Rehabilitation, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi, 465-8620, Japan
| | - Ikuko Aiba
- Department of Neurology, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi, 465-8620, Japan
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Mowforth OD, Davies BM, Kotter MR. The Use of Smart Technology in an Online Community of Patients With Degenerative Cervical Myelopathy. JMIR Form Res 2019; 3:e11364. [PMID: 31094330 PMCID: PMC6532340 DOI: 10.2196/11364] [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: 06/21/2018] [Revised: 01/13/2019] [Accepted: 01/27/2019] [Indexed: 11/22/2022] Open
Abstract
Background Degenerative cervical myelopathy (DCM) is a prevalent and progressively disabling neurological condition. Treatment is currently limited to surgery, the timing of which is not without controversy. New international guidelines recommend that all patients should undergo lifelong surveillance and those with moderate-to-severe or progressive disease should be offered surgery. Long-term surveillance will place substantial burden on health services and short clinic assessments may risk misrepresenting disease severity. The use of smart technology to monitor disease progression could provide an invaluable opportunity to lessen this burden and improve patient care. However, given the older demographic of DCM, the feasibility of smart technology use is unclear. Objective The aim of this study was to investigate current usage of smart technology in patients with self-reported DCM to inform design of smart technology apps targeted at monitoring DCM disease progression. Methods Google Analytics from the patient section of Myelopathy.org, an international DCM charity with a large online patient community, was analyzed over a 1-year period. A total of 15,761 sessions were analyzed. Results In total, 39.6% (295/744) of visitors accessed the website using a desktop computer, 35.1% (261/744) using mobile, and 25.3% (188/744) using a tablet. Of the mobile and tablet visitors, 98.2% (441/449) utilized a touchscreen device. A total of 51.3% (141/275) of mobile and tablet visitors used iPhone Operating System (iOS) and 45.8% (126/275) used an Android operating system. Apple and Samsung were the most popular smart devices, utilized by 53.6% (241/449) and 25.8% (116/449) of visitors, respectively. The overall visitor age was representative of DCM trials. Smart technology was widely used by older visitors: 58.8% (113/192) of mobile visitors and 84.2% (96/114) of tablet visitors were aged 45 years or older. Conclusions Smart technology is commonly used by DCM patients. DCM apps need to be iOS and Android compatible to be accessible to all patients.
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Affiliation(s)
- Oliver Daniel Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Benjamin Marshall Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Mark Reinhard Kotter
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Abstract
STUDY DESIGN .: Prospective cohort study. OBJECTIVE .: Analyze GRF parameters in cervical spondylotic myelopathy (CSM) patients to elucidate gait alterations as compared with healthy controls. SUMMARY OF BACKGROUND DATA .: During the human gait cycle, the magnitude and direction of the force each foot imparts on the ground varies in a controlled fashion to propel the body's center of mass forward. Alterations in GRF patterns can both point to subtle gait disturbances and explain altered gait patterns such as that seen in CSM. METHODS .: Thirty-two patients with symptomatic CSM who have been scheduled for surgery, along with 30 healthy controls (HC), underwent clinical gait analysis a week before surgery. Vertical GRF parameters and force magnitude and timing at various points of the gait cycle (i.e., heel contact, maximum weight acceptance, mid-stance, and push off) were analyzed and compared between groups. RESULTS .: Increased heel contact (CSM: 60.13% vs. HC: 27.82% of body weight, BW,P = 0.011), maximum weight acceptance (CSM: 120.13% vs. HC: 100.97% of BW, P = 0.016), and diminished push off (CSM: 91.35% vs. HC: 106.54% of BW, P = 0.001) forces were discovered in CSM patients compared with HC. Compared with controls CSM patients had delayed heel contact (CSM: 9.32% vs. HC: 5.12% of gait cycle, P = 0.050) and earlier push off (CSM: 54.96% vs. HC: 59.0% of gait cycle, P = 0.050), resulting in a shorter stance phase. CONCLUSION .: This study reinforces how CSM patients commonly exhibit altered gait patterns, but also uniquely demonstrates the increased heel-contract and maximum weight acceptance forces, diminished toe-off forces, and the shorter stance phase to absorb the BW load. When examined from a global perspective, these altered GRF parameters reflect the difficulty CSM patients have with catching their center of mass during heel-contact to avoid falling and with subsequently propelling themselves forward. LEVEL OF EVIDENCE 3.
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Abstract
STUDY DESIGN This is a prospective cohort study. OBJECTIVE To evaluate the effect of cervical decompression surgery on the biomechanics of the spine and lower extremities in cervical spondylotic myelopathy (CSM) patients and compare with asymptomatic controls. SUMMARY OF BACKGROUND DATA Difficulties with balance and gait are one of the most common manifestations of CSM. Patients with CSM have a slower gait speed, prolonged double support duration, and reduced cadence compared with healthy controls. Surgical decompression was found to improve clinical outcomes, but conflicting results are noted when examining function. MATERIALS AND METHODS In total, 25 subjects with symptomatic CSM underwent clinical gait analysis performed a week before (pre) and 3 months after the surgery (post). Clinical gait analysis was performed on 30 matched asymptomatic controls as well. Spine and lower extremity kinematics, spatiotemporal parameters, and clinical outcome were measured. RESULTS CSM patients demonstrated slower walking speed (P=0.006), reduced cadence (P=0.001), longer step time (P=0.013) wider step width (P=0.001), greater ankle range of motion (ROM) (P=0.019), less hip ROM (P=0.050), increased pelvis (P=0.001), and lumbar spine (P=0.049) ROM compared with controls. Postoperatively CSM patients demonstrated a faster walking speed (P=0.002), increased cadence (P=0.029), longer step length (P=0.015), narrower step width (P=0.004), greater knee (P=0.043), and hip ROM (P=0.007), less pelvis (P=0.002), lumbar spine (P=0.035), and cervical spine (P=0.044) ROM, and improved clinical outcomes (neck pain disability index questionnaire, oswestry disability index, and visual analog scale; P=0.001) compared with their preoperative values. Postsurgical CSM patients did not present with any differences compared with controls, beside pelvis ROM (P=0.019). CONCLUSIONS Preoperatively, CSM patients clearly showed altered gait parameters compared with controls. However, after cervical decompression surgery, CSM patients exhibited improved gait pattern, spatiotemporal parameters, spine and lower extremity ROM, as well as patient-reported outcomes. Postoperatively, CSM patients did not show major differences in gait when compared with matched asymptomatic controls.
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Haddas R, Patel S, Arakal R, Boah A, Belanger T, Ju KL. Spine and lower extremity kinematics during gait in patients with cervical spondylotic myelopathy. Spine J 2018; 18:1645-1652. [PMID: 29746965 DOI: 10.1016/j.spinee.2018.04.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/14/2018] [Accepted: 04/09/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cervical spondylotic myelopathy (CSM) typically manifests with a slow, progressive stepwise decline in neurologic function, including hand clumsiness and balance difficulties. Gait disturbances are frequently seen in patients with CSM, with more advanced cases exhibiting a stiff, spastic gait. PURPOSE To evaluate the spatiotemporal parameters and spine and lower extremity kinematics during the gait cycle of adult patients with CSM before surgical intervention. STUDY DESIGN Prospective cohort study. PATIENT SAMPLE Twenty-eight subjects with symptomatic CSM who have been scheduled for surgery and 30 healthy controls (HC). OUTCOME MEASURES Spine and lower extremity kinematics and spatiotemporal parameters. METHODS Clinical gait analysis was performed for patients with CSM and HC. The data were analyzed with a one-way analysis of variance. RESULTS Patients with CSM have significantly more anterior pelvis tilt (CSM: 13.97°, HC: 5.56°), larger lumbar lordosis (CSM: 8.59°, HC: 2.7°), smaller cervical lordosis (CSM: 6.02°, HC: 11.35°), and less head flexion (CSM: 0.69°, HC: 8.66°) at the beginning of the gait cycle. There was a decrease in knee range of motion in patients with CSM compared with controls (CSM: 36.31°, HC: 50.17°). Furthermore, patients with CSM presented with slower walking speed (CSM: 0.81 m/s, HC: 1.05 m/s), decreased cadence (CSM: 95.57 step/m, HC: 107.64 step/m), increased double support time (CSM: 0.40 s, HC: 0.28 s) and stride time (CSM:1.28 s, HC: 1.13 s), shorter stride length (CSM: 1.04 m, HC: 1.18 m) and step length (CSM:0.51 m, HC: 0.58 m), and wider width (CSM: 0.14 m, HC:0.11 m). CONCLUSIONS Our study shows that patients with CSM enter the gait cycle with a larger anterior pelvic tilt and lumbar lordosis as well as less cervical lordosis and head flexion. As a consequence of these abnormal spinal parameters at the onset of the gait cycle, lower extremity biomechanics are also altered. Our study is the first to demonstrate the relationship between aberrant spinal alignment and lower extremity function. Identification of this interrelationship as well as the specific gait and biomechanical disturbances seen in myelopathic patients can both inform our understanding of the disease and tailor rehabilitation protocols.
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Affiliation(s)
- Ram Haddas
- Texas Back Institute Research Foundation, 6020 West Parker Rd, Plano, TX 75093, USA.
| | - Sujal Patel
- Oasis Medical and Surgical Wellness Group, 85 Harristown Rd, Glen Rock, NJ 07452, USA
| | - Raj Arakal
- Texas Back Institute, 6020 West Parker Rd, Plano, TX 75093, USA
| | - Akwasi Boah
- Texas Back Institute, 3537 W Oak St #308, Denton, TX 76201, USA
| | | | - Kevin L Ju
- Texas Back Institute, 3164 Horizon Rd #100, Rockwall, TX 75032, USA
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Haddas R, Ju KL, Belanger T, Lieberman IH. The use of gait analysis in the assessment of patients afflicted with spinal disorders. 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 2018; 27:1712-1723. [PMID: 29610989 DOI: 10.1007/s00586-018-5569-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE Use gait analysis to establish and detail the clinically relevant components of normal human gait, analyze the gait characteristics for those afflicted with spinal pathology, and identify those aspects of human gait that correlate with pre- and postoperative patient function and outcomes. METHODS Twenty patients with adult degenerative scoliosis (ADS), 20 patients with cervical spondylotic myelopathy (CSM), and 15 healthy volunteers performed over-ground gait trials with a comfortable self-selected speed using video cameras to measure patient motion, surface electromyography (EMG) to record muscle activity, and force plates to record ground reaction force (GRF). Gait distance and temporal parameters, ankle, knee, hip, pelvic, and trunk range of motion (ROM), duration of lower extremity EMG activity and peak vertical GRF were measured. RESULTS Patients with ADS and CSM exhibited a significantly slower gait speed, decrease in step length, cadence, longer stride time, stance time, double support time, and an increase in step width compared to those in the control group. These patients also exhibited a significantly different ankle, knee, pelvic, and trunk ROM. Moreover, spinal disorder patients exhibited a significantly longer duration of rectus femoris, semitendinosus, tibialis anterior and medial gastrocnemius muscle activity along with an altered vertical GRF pattern. CONCLUSIONS Gait analysis provides an objective measure of functional gait in healthy controls as well as those with ADS and CSM. This study established and detailed some of the important kinematic and kinetic variables of gait in patients with spinal disorders. We recommend that spine care providers use gait analysis as part of their clinical evaluation to provide an objective measure of function. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Ram Haddas
- Texas Back Institute, 6020 W. Parker Road, Suite 200, Plano, TX, 75093, USA.
| | | | | | - Isador H Lieberman
- Texas Back Institute, 6020 W. Parker Road, Suite 200, Plano, TX, 75093, USA
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Nagai T, Takahashi Y, Endo K, Ikegami R, Ueno R, Yamamoto K. Analysis of spastic gait in cervical myelopathy: Linking compression ratio to spatiotemporal and pedobarographic parameters. Gait Posture 2018; 59:152-156. [PMID: 29031141 DOI: 10.1016/j.gaitpost.2017.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/07/2017] [Accepted: 10/08/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Gait dysfunction associated with spasticity and hyperreflexia is a primary symptom in patients with compression of cervical spinal cord. The objective of this study was to link maximum compression ratio (CR) to spatiotemporal/pedobarographic parameters. METHODS Quantitative gait analysis was performed by using a pedobarograph in 75 elderly males with a wide range of cervical compression severity. CR values were characterized on T1-weighted magnetic resonance imaging (MRI). Statistical significances in gait analysis parameters (speed, cadence, stride length, step with, and toe-out angle) were evaluated among different CR groups by the non-parametric Kruskal-Wallis test followed by the Mann-Whitney U test using Bonferroni correction. The Spearman test was performed to verify correlations between CR and gait parameters. RESULTS The Kruskal-Wallis test revealed significant decline in gait speed and stride length and significant increase in toe-out angle with progression of cervical compression myelopathy. The post-hoc Mann-Whitney U test showed significant differences in these parameters between the control group (0.45<CR) and the worst myelopathy group (CR≤0.25). Cadence and step width did not significantly change with CR. On the other hand, the Spearman test revealed that CR was significantly correlated with speed, cadence, stride length, and toe-out angle. CONCLUSION Gait speed, stride length, and toe-out angle can serve as useful indexes for evaluating progressive gait abnormality in cervical myelopathy. Our findings suggest that CR≤0.25 is associated with significantly poorer gait performance. Nevertheless, future prospective studies are needed to determine a potential benefit from decompressive surgery in such severe compression patients.
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Affiliation(s)
- Taro Nagai
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Yasuhito Takahashi
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan; Department of Bone and Joint Biomaterial Research, Tokyo Medical University, 6-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan.
| | - Kenji Endo
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Ryo Ikegami
- Rehabilitation Center, Tokyo Medical University Hospital, 6-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Ryuichi Ueno
- Rehabilitation Center, Tokyo Medical University Hospital, 6-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Kengo Yamamoto
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
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Haddas R, Belanger T. Clinical Gait Analysis on a Patient Undergoing Surgical Correction of Kyphosis from Severe Ankylosing Spondylitis. Int J Spine Surg 2017; 11:18. [PMID: 28765802 DOI: 10.14444/4018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Ankylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting the axial skeleton, including the sacroiliac joints, costovertebral joints, and the spine. Patients with AS found to have an alter gait pattern. The purpose of this study was to investigate biomechanical alterations in gait after surgical correction in a patient with severe kyphosis from AS. METHODS A case report in controlled laboratory study, a pretest-posttest design. A 20 year-old male presented with severe sagittal imbalance and inability to stand erect due to AS. He presented with thoracic kyphosis of 70°, lumbar kyphosis of 25°, and pelvic incidence of 43°. The patient had a complex spinal reconstruction with 84° of sagittal correction, normalizing his sagittal alignment. Gait analysis was performed the day before surgery and one month post surgery, including three-dimensional kinematics, ground reaction forces, and electromyography outcomes. RESULTS Normalization of spinal alignment minimally increased walking speed and cadence. Lower extremity ranges of motion angles increased, but were not symmetrical even one month post surgery. Postoperatively, trunk flexion, neck extension and head orientation angles decreased compared with preoperative values, but was not symmetrical even one month post surgery. The trunk muscles were activated earlier in the post surgery condition compared to the pre surgery condition while lower extremity muscles presented later muscle activation. CONCLUSIONS Surgical correction of spinal alignment improved spine function and efficiency. Changes in gait abnormality parameters observed imply that the patient used less energy to ambulate after surgery than before surgery. Although pre-surgery data showed compensation in the spine kinematics, post-surgery data supported significant changes in the spine and the lower extremity values. CLINICAL RELEVANCE Formal gait and motion analysis can provide a method to assess the impact of severe spinal deformity on function and changes after treatment.
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Affiliation(s)
- Ram Haddas
- Texas Back Institute Research Foundation, Plano, TX, USA
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24
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Siasios ID, Spanos SL, Kanellopoulos AK, Fotiadou A, Pollina J, Schneider D, Becker A, Dimopoulos VG, Fountas KN. The Role of Gait Analysis in the Evaluation of Patients with Cervical Myelopathy: A Literature Review Study. World Neurosurg 2017; 101:275-282. [PMID: 28192261 DOI: 10.1016/j.wneu.2017.01.122] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/27/2017] [Accepted: 01/30/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Gait analysis represents one of the newest methodologies used in the clinical evaluation of patients with cervical myelopathy (CM). OBJECTIVE To describe the role of gait analysis in the clinical evaluation of patients with CM, as well as its potential role in the evaluation of the functional outcome of any surgical intervention. METHODS A literature review was performed in the PubMed, OVID, and Google Scholar medical databases, from January 1995 to August 2016, using the terms "analysis," "anterior," "cervical myelopathy," "gait," "posterior," and "surgery." Clinical series comparing the gait patterns of patients with CM with healthy controls, as well as series evaluating gait and walk changes before and after surgical decompression, were reviewed. Case studies were excluded. RESULTS Nine prospective and 3 retrospective studies were found. Most of the retrieved studies showed the presence of characteristic, abnormal gait patterns among patients with CM, consisting of decreased gait speed, cadence, step length, stride length, and single-limb support time. In addition, patients with CM routinely present increased step and stride time, double-limb support time, and step width, and they have altered knee and ankle joint range of motion, compared with healthy controls. Moreover, gait and walk analysis may provide accurate functional assessment of the functional outcome of patients with CM undergoing surgical decompression. CONCLUSIONS Gait analysis may well be a valuable and objective tool along with other parameters in the evaluation of functionality in patients with CM, as well as in the assessment of the outcome of any surgical intervention in these patients.
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Affiliation(s)
- Ioannis D Siasios
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA; Department of Neurosurgery, School of Medicine, University of Thessaly, Larisa, Greece.
| | - Savvas L Spanos
- Department of Physical Therapy, School of Health and Welfare, Central Greece University of Applied Sciences, Lamia, Greece
| | - Asimakis K Kanellopoulos
- Department of Physical Therapy, School of Health and Welfare, Central Greece University of Applied Sciences, Lamia, Greece
| | - Aggeliki Fotiadou
- Department of Neurosurgery, School of Medicine, University of Thessaly, Larisa, Greece
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA
| | - Daniel Schneider
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Alexander Becker
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Vassilios G Dimopoulos
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA
| | - Kostas N Fountas
- Department of Neurosurgery, School of Medicine, University of Thessaly, Larisa, Greece
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25
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Bohm PE, Fehlings MG, Kopjar B, Tetreault LA, Vaccaro AR, Anderson KK, Arnold PM. Psychometric properties of the 30-m walking test in patients with degenerative cervical myelopathy: results from two prospective multicenter cohort studies. Spine J 2017; 17:211-217. [PMID: 27592193 DOI: 10.1016/j.spinee.2016.08.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 07/06/2016] [Accepted: 08/29/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The timed 30-m walking test (30MWT) is used in clinical practice and in research to objectively quantify gait impairment. The psychometric properties of 30MWT have not yet been rigorously evaluated. PURPOSE This study aimed to determine test-retest reliability, divergent and convergent validity, and responsiveness to change of the 30MWT in patients with degenerative cervical myelopathy (DCM). STUDY DESIGN/SETTING A retrospective observational study was carried out. PATIENT SAMPLE The sample consisted of patients with symptomatic DCM enrolled in the AOSpine North America or AOSpine International cervical spondylotic myelopathy studies at 26 sites. OUTCOME MEASURES Modified Japanese Orthopaedic Association scale (mJOA), Nurick scale, 30MWT, Neck Disability Index (NDI), and Short-Form-36 (SF-36v2) physical component score (PCS) and mental component score (MCS) were the outcome measures. METHODS Data from two prospective multicenter cohort myelopathy studies were merged. Each patient was evaluated at baseline and 6 months postoperatively. RESULTS Of 757 total patients, 682 (90.09%) attempted to perform the 30MWT at baseline. Of these 682 patients, 602 (88.12%) performed the 30MWT at baseline. One patient was excluded, leaving601 in the analysis. At baseline, 81 of 682 (11.88%) patients were unable to perform the test, and their mJOA, NDI, and SF-36v2 PCS scores were lower compared with those who performed the test at baseline. In patients who performed the 30MWT at baseline, there was very high correlation among the three baseline 30MWT measurements (r=0.9569-0.9919). The 30MWT demonstrated good convergent and divergent validity. It was moderately correlated with the Nurick (r=0.4932), mJOA (r=-0.4424), and SF-36v2 PCS (r=-0.3537) (convergent validity) and poorly correlated with the NDI (r=0.2107) and SF-36v2 MCS (r=-0.1984) (divergent validity). Overall, the 30MWT was not responsive to change (standardized response mean [SRM]=0.30). However, for patients who had a baseline time above the median value of 29 seconds, the SRM was 0.45. CONCLUSIONS The 30MWT shows high test-retest reliability and good divergent and convergent validity. It is responsive to change only in patients with more severe myelopathy. The 30MWT is a simple, quick, and affordable test, and should be used as an ancillary test to evaluate gait parameters in patients with DCM.
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Affiliation(s)
- Parker E Bohm
- Department of Neurosurgery, University of Kansas Medical Center, Mail Stop 3021, 3901 Rainbow Blvd, Kansas City, KS 66160 USA
| | - Michael G Fehlings
- Department of Surgery, University of Toronto, Toronto Western Hospital, University Health Network, 399 Bathurst St, #4W-449, Toronto, Ontario M5T 2S8 Canada
| | - Branko Kopjar
- Department of Health Services, University of Washington, 4333 Brooklyn Ave NE, Rm #14-315, Seattle, WA 98195, USA
| | - Lindsay A Tetreault
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto Western Hospital, University Health Network, 399 Bathurst St, #4W-449, Toronto, Ontario M5T 2S8 Canada
| | - Alexander R Vaccaro
- Departments of Orthopaedic Surgery and Neurological Surgery, The Rothman Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107 USA
| | - Karen K Anderson
- Department of Neurosurgery, University of Kansas Medical Center, Mail Stop 3021, 3901 Rainbow Blvd, Kansas City, KS 66160 USA
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center, Mail Stop 3021, 3901 Rainbow Blvd, Kansas City, KS 66160 USA.
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Spinal Disorders as a Cause of Locomotive Syndrome: The Influence on Functional Mobility and Activities of Daily Living. Clin Rev Bone Miner Metab 2016. [DOI: 10.1007/s12018-016-9213-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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