Adam Graf

Long-Term Outcome Evaluation in Young Adults Following Clubfoot Surgical Release

Background The aim of this study was to evaluate the long-term outcome of a comprehensive surgical release for congenital talipes equinovarus (CTEV). Methods Gait, strength, segmental foot motion, and outcomes questionnaire data were collected on 24 adults (21.8±2.3 y) who were surgically treated for CTEV as infants. These data were statistically compared with of 48-age group matched controls (23.2±2.4 y). Results The clubfoot group was functional in activities of daily living, although most patients did experience foot pain after a day of typical activities, such as walking, standing, using stairs and doing exercise. Lower extremity gait kinematics was similar to the control group. There were differences in segmental foot motion with the hindfoot in a more plantarflexed position relative to the tibia and the forefoot dorsiflexed, and adducted relative to the hindfoot. Ankle plantarflexion and inversion strength and range of motion was reduced in the clubfoot group in association with an increase in hip power generation during the preswing and initial swing phases of the gait cycle. Conclusions Surgical correction of CTEV was successful in providing a functional plantigrade foot as the patients reached adulthood. However, limitations included foot pain, limited foot range of motion, and weakness. Level of Evidence Level III.

Repeatability and sources of variability in multi-center assessment of segmental foot kinematics in normal adults

Multi-site application of biomechanical models can be a powerful tool as quantitative methods are employed to improve clinical care and to assess larger populations for research purposes. However, the use of such models depends on adequate validation to assure reliability in inter-site measures. We assessed repeatability and sources of variability associated with the assessment of segmental foot kinematics using the Milwaukee Foot Model during multiple testing sessions at two sites. Six healthy ambulators were instrumented and tested during comfortable ambulation; data were analyzed with variance components analysis using a mixed effects linear model. Results indicated that the largest source of variability was inter-subject; measurement error associated with Site and Session fell below 3.5 degrees in over 80% of position measurements and below 2.5 degrees in over 80% of ROM measurements. These findings support the continued use of the segmental foot model at multiple sites for clinical and research purposes.

Ankle strength and functional limitations in children and adolescents with type I osteogenesis imperfecta.

Purpose: To determine whether children with type I osteogenesis imperfecta (OI) exhibit ankle plantar flexor weakness and whether this correlates with physical function. Methods: Twenty children and adolescents with type I OI and 20 age-matched controls (age 6-18 years) participated in a single evaluation session. Data included strength assessment, Gillette Functional Assessment Questionnaire, Pediatric Outcome Data Collection Instrument (PODCI), and Faces Pain Scale—Revised. Results: Ankle plantar flexor weakness was evident in the OI group compared with the control group. Heel-rise strength correlated with ankle isometric plantar flexion strength. Limitations in PODCI subscales—sports and physical function and pain/comfort—are present in the OI group. Conclusion: Ankle plantar flexor weakness is present in children and adolescents with type I OI and correlates with function. Gillette Functional Assessment Questionnaire, PODCI, and strength assessment are valuable evaluation tools for children and adolescents with type I OI and can aid therapists in goal setting.

Gait characteristics and functional assessment of children with Type I Osteogenesis Imperfecta

The purpose of this study was to improve the evaluation process of children with type I Osteogenesis Imperfecta (OI) by providing a quantitative comparison of gait and selected functional assessments to age‐matched controls. A 14‐camera Vicon Motion Analysis System was used for gait analysis along with selected functional assessments (Pediatric Outcomes Data Collection Instrument [PODCI], Functional Assessment Questionnaire [FAQ], Faces Pain Scale‐Revised [FPS‐R]) conducted on 10 subjects with type I OI and 22 age‐matched healthy controls. The results of the OI group demonstrated abnormal gait parameters including increased double support, delayed foot off, reduced ankle range of motion and plantarflexion during third rocker, along with greater ankle power absorption during terminal stance and reduced ankle power generation during push off. The functional assessment scores of the OI group were similar to the control group for basic mobility and function, but were lower than their peers in the sports and physical function category. The evaluation of individuals with OI by means of gait analysis and selected functional assessments, along with an accurate biomechanical model of the lower extremities, is proposed to better understand and predict OI disability and improve quality of life.

Brace evaluation in children with diplegic cerebral palsy with a jump gait pattern.

BACKGROUND Brace prescription for children with diplegic cerebral palsy challenges the clinician with a variety of options and little evidence for rational decisions. Previous studies have indicated that ankle-foot orthoses improve toe-walking, but it is unclear if any brace is better than another. The goal of the present study was to compare the effectiveness of hinged and dynamic ankle-foot orthoses in terms of improving gait and motor function in a homogeneous group of children with diplegic cerebral palsy exhibiting a jump gait pattern. METHODS Fifteen children (mean age, 7.5 years) with spastic diplegic cerebral palsy who were able to walk independently with a jump gait pattern and twenty children (mean age, 10.6 years) with normal gait participated in the study. Standardized Gross Motor Function Classification System scores, Pediatric Outcomes Data Collection Instrument scores, and gait data were collected, analyzed, and compared. The subjects were tested while barefoot and while wearing hinged and dynamic ankle-foot orthoses. Data were analyzed to detect differences among these conditions. RESULTS Significant improvements in gait metrics were seen during brace wear. No significant differences were seen between the two different braces used. The barefoot and braced conditions differed most significantly in terms of ankle kinematics and kinetics. Among the patients with cerebral palsy, no significant differences in the standardized outcome measurements were found between the braced and unbraced conditions or between the two braced conditions. CONCLUSIONS Our data suggest that gait improves with brace wear in children with cerebral palsy with a level-I Gross Motor Function Classification System score. The Pediatric Outcomes Data Collection Instrument and the Gross Motor Function Measure were not sensitive to brace treatment in the population studied. The hinged and dynamic braces were equally effective for improving ankle kinematics and kinetics in these relatively highly functioning children with cerebral palsy.

Kinematic Foot Types in Youth with Equinovarus Secondary to Hemiplegia

BACKGROUND Elevated kinematic variability of the foot and ankle segments exists during gait among individuals with equinovarus secondary to hemiplegic cerebral palsy (CP). Clinicians have previously addressed such variability by developing classification schemes to identify subgroups of individuals based on their kinematics. OBJECTIVE To identify kinematic subgroups among youth with equinovarus secondary to CP using 3-dimensional multi-segment foot and ankle kinematics during locomotion as inputs for principal component analysis (PCA), and K-means cluster analysis. METHODS In a single assessment session, multi-segment foot and ankle kinematics using the Milwaukee Foot Model (MFM) were collected in 24 children/adolescents with equinovarus and 20 typically developing children/adolescents. RESULTS PCA was used as a data reduction technique on 40 variables. K-means cluster analysis was performed on the first six principal components (PCs) which accounted for 92% of the variance of the dataset. The PCs described the location and plane of involvement in the foot and ankle. Five distinct kinematic subgroups were identified using K-means clustering. Participants with equinovarus presented with variable involvement ranging from primary hindfoot or forefoot deviations to deformtiy that included both segments in multiple planes. CONCLUSION This study provides further evidence of the variability in foot characteristics associated with equinovarus secondary to hemiplegic CP. These findings would not have been detected using a single segment foot model. The identification of multiple kinematic subgroups with unique foot and ankle characteristics has the potential to improve treatment since similar patients within a subgroup are likely to benefit from the same intervention(s).

Comprehensive review of the functional outcome evaluation of clubfoot treatment: a preferred methodology.

Treatment outcome has been a focus of interest in those who manage clubfeet. Because of a lack of a common evaluation protocol, it has become necessary to establish a universally recognized quantitative measurement to compare and better understand the treatment outcome. The outcome is not merely morphological and radiographic, but it should also include functional and quality-of-life measurements. In this article, we will outline the most commonly used methods of long-term evaluation for congenital clubfeet and recommend the data collection parameters that are most appropriate for a comprehensive functional analysis. This will begin with pretreatment classifications that are important in prognosticating the results. The physical examinations and plain radiographs in standing position are also two fundamental evaluations of clubfoot. Several outcome evaluations have been published in the literature and may be useful depending on the desired metrics. Gait analysis is an additional useful technical tool for analyzing the motion of the foot and ankle and its relation to the whole body function; pedobarography added to the dynamics of the evaluation. Functional quality-of-life questionnaires are increasing in popularity for measuring the total body functional status and the quality of life.

Effect of Lowest Instrumented Vertebra on Trunk Mobility in Patients With Adolescent Idiopathic Scoliosis Undergoing a Posterior Spinal Fusion

STUDY DESIGN Prospective. OBJECTIVES The goal of this study was to evaluate the effect of posterior spinal fusion surgery terminating at different lowest instrumented vertebrae (LIV) on trunk mobility in individuals with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA Posterior spinal fusion with instrumentation is the standard surgical technique employed in AIS for correcting spine deformities with Cobb angles exceeding 50°. Surgical correction of curve deformity reduces trunk mobility and range of motion. However, conflicting findings from previous studies investigating the impact of different LIV levels on the reduction in trunk mobility after surgery have been reported. METHODS The study was designed as a prospective study with 47 patients (7 males and 40 females) with AIS who underwent posterior spinal fusion. Patients were classified into 5 groups based on their surgical LIV level (ie, T12, L1, L2, L3, and L4). Trunk flexion-extension (sagittal plane), lateral bending (coronal plane), and axial rotation (transverse plane) kinematics were assessed during preoperative, 1 year postoperative, and 2 years postoperative evaluation visits. RESULTS There were postoperative reductions of 41%, 51%, and 59% in trunk range of motion in the sagittal, coronal, and transverse planes, respectively (p < .0001). A trend toward greater postoperative reductions in peak forward flexion at more distal LIVs was observed (p = .04). CONCLUSIONS Fusion reduces trunk mobility in the sagittal, coronal, and transverse planes. More distal LIV fusions limit peak forward flexion to a greater extent which is considered clinically significant. After fusion, the reductions seen in axial rotation, lateral bending, and backward extension do not differ significantly at more distal LIVs.

Application of a bi-planar postural stability model in children with cerebral palsy

This study presents initial results from a bi-planar model used to investigate the neurological factors affecting balance deficits in children with diplegic cerebral palsy (CP). The model uses an inverted pendulum to describe sway in both the anteroposterior (AP) and mediolateral (ML) planes. The study presents Center of Pressure (COP) data from 17 children diagnosed with spastic diplegic CP using two standard AMTI force plates. Sway metrics in the time and frequency domains in the AP and ML planes were calculated and compared to simulations produced by the model. The proposed bi-planar model successfully reproduced sway signals acquired from experimental (clinical) data.

Upper extremity wheelchair kinematics in children with Spinal Cord Injury

Current methods for the evaluation of upper extremity dynamics during wheelchair mobility in children are limited. The goal of this study was to characterize upper extremity joint kinematics during wheelchair mobility. A 3-D biomechanical model of the upper extremities is presented for kinematic assessment of manual wheelchair propulsion in children with Spinal Cord Injury (SCI). The bilateral upper extremity model consists of the thorax, upper arms, forearms, and hands. The model was applied to thirteen (13) children with SCI. Joint angles and joint ranges of motion of the shoulders, elbows, and wrists were quantified. Peak joint motions during the stroke cycle were compared between right and left sides for further insight to mobility patterns. This work will provide insight to be used in future kinetic studies of wheelchair mobility.