Bonita Sawatzky

Radiographic Assessment of Adult Flatfoot

Background: The accurate measurement of flatfoot on standing radiographs allows correct diagnosis of the condition and evaluation of reconstructive procedures. Method: The standing radiographic measurements of patients with symptomatic, adult flatfoot were compared to controls using blinded observers.Results: On the lateral radiograph, the talar-to-first metatarsal angle, the calcaneal pitch angle, and the medial cuneiform-fifth metatarsal height differed significantly between the patient group and the controls. The difference in the talar-to-first metatarsal angles on lateral radiographs was the most statistically significant (patient group 21.1 ±10.8 degrees and control 7.1 ± 10.7 degrees, p < 0.0001) with good correlation between readings (intraobserver 0.75, interobserver 0.83). On the anteroposterior (AP) radiograph, the talar head uncoverage distance was the most significantly different measurement between these groups. Conclusions: These findings support the hypothesis that the talar-first metatarsal angle is an accurate radiographic identifier of patients with symptomatic, adult flatfoot.

Preliminary Outcomes of the SmartWheel Users’ Group Database: A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion

OBJECTIVES To describe a standard clinical protocol for the objective assessment of manual wheelchair propulsion; to establish preliminary values for temporal and kinetic parameters derived from the protocol; and to develop graphical references and a proposed application process for use by clinicians. DESIGN Case series. SETTING Six research institutions that collect kinetic wheelchair propulsion data and contribute that data to an international data pool. PARTICIPANTS Subjects with spinal cord injury (N=128). INTERVENTIONS Subjects propelled a wheelchair from a stationary position to a self-selected velocity across a hard tile surface, a low pile carpet, and up an Americans with Disabilities Act-compliant ramp. Unilateral kinetic data were obtained from subjects using a force and moment sensing pushrim. MAIN OUTCOME MEASURES Differences in self-selected velocity, peak resultant force, push frequency, and stroke length across all surfaces, relationship between (1) weight-normalized peak resultant force and self-selected velocity and (2) push frequency and self-selected velocity. RESULTS Graphical references were generated for potential clinical use based on the relation between body weight-normalized peak resultant force, push frequency, and velocity. Self-selected velocity decreased (ramp < carpet < tile), peak resultant forces increased (ramp > carpet > tile), and push frequency and stroke length remained unchanged when compared across the different surfaces. Weight-normalized peak resultant force was a significant predictor of velocity on tile and ramp. Push frequency was a significant predictor of velocity on tile, carpet, and ramp. CONCLUSIONS We present preliminary data generated from a clinically practical manual wheelchair propulsion evaluation protocol and we describe a proposed method for clinicians to objectively evaluate manual wheelchair propulsion.

Treatment of idiopathic clubfoot utilizing botulinum A toxin: a new method and its short-term outcomes.

A pivotal point in most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of botulinum A toxin (BTX-A) in attenuating the function of the triceps surae muscle complex as an alternative to tenotomy was investigated. Fifty-one patients with 73 idiopathic clubfeet were recruited. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: group 1 (<30 days old) and group 2 (>30 days and <8 months old). Ankle dorsiflexion in knee flexion and extension remained above 20 degrees and 15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. One of the 51 patients required limited posterior release and 9 patients required repeat manipulation and casting plus or minus BTX-A injection. The use of BTX-A as an adjunctive therapy in the noninvasive approach of manipulation and casting in idiopathic clubfoot is a safe and effective treatment.

The Internet is valid and reliable for child-report: an example using the Activities Scale for Kids (ASK) and the Pediatric Quality of Life Inventory (PedsQL).

OBJECTIVE This study tested the impact of web administration on well-established measures of childrens physical function and quality of life. STUDY DESIGN AND SETTING Participants were recruited from clinics at six hospitals. They completed the Activities Scale for Kids (ASK) and the Pediatric Quality of Life Inventory (PedsQL) questionnaires twice, in a crossover design that used paper and web-based modes of administration. Intraclass correlation coefficients were used to assess the validity of the new web formats relative to the original paper formats and their test-retest reliability. RESULTS Sixty-nine children ranging in age from 8.0 to 13.4 years (mean=11.0 years) completed the study. The sample included children with cerebral palsy (19), spina bifida (23), and cystic fibrosis (27). The mean ASK score was 77.5 and the mean PedsQL score was 69.1. The intermethod intraclass correlation coefficients were 0.98 (lower limit 0.94) for the ASK and 0.64 (lower limit 0.35) for the PedsQL. These compare to intraclass correlation coefficients of 0.99 and 0.94, respectively, for traditional paper formats. CONCLUSION The web ASK was valid in comparison to the original paper format. Consistency in mode of administration may be more important when using the PedsQL. Both measures were highly reliable on paper and on the web.

Prevalence of shoulder pain in adult- versus childhood-onset wheelchair users: A pilot study

Shoulder pain is a common overuse problem in long-term adult wheelchair users. The current study examined whether the prevalence of shoulder pain in adult wheelchair users who began using their wheelchairs during childhood (childhood-onset [CH-O] group) is similar to those who began using their wheelchairs as adults (adult-onset [AD-O] group). We compared 31 CH-O and 22 AD-O wheelchair users using the Wheelchair Users Shoulder Pain Index (WUSPI), an overall pain score (Brief Pain Inventory), and a lifestyle questionnaire to determine frequency and duration of physical activity. Shoulder pain (WUSPI) was greater in the AD-O wheelchair users compared with the CH-O group (p < 0.008), even though their general lifestyles were not different. The immature skeleton can possibly respond to the repetitive forces of wheeling better than that of those who begin using a wheelchair once their skeletal structure is completely developed.

The ergonomics of different tyres and tyre pressure during wheelchair propulsion.

It is believed that the newer solid tyres on wheelchairs perform as well as pneumatic tyres along with less cost and time for maintenance. The questions are: (1) do solid tyres perform as well as pneumatic tyres and (2) what is the critical level of pneumatic tyre pressure before wheeling efficiency decreases? Part one measured the rolling resistance differences of five commonly used wheelchair tyres (three pneumatic and two solid) under four different tyre pressures (100, 75, 50 and 25 of inflation). Part two measured the oxygen consumption in 15 participants with paraplegia, during wheelchair propulsion, comparing the same four levels of tyre inflation. The solid tyres performed worse than all three pneumatic tyres even when tyres were under-inflated to 25% of tyre pressure. Two of the pneumatic tyres showed significant decreases in rolling between 100 and 50%, but there were no significant differences in rolling distance between 100 and 75% pressure. The physiological study showed that energy expenditure increased significantly at 50% of tyre-inflation. Health care facilities are finding ways to decrease cost by using solid tyres on all wheelchairs. This study shows that benefits to clients and staff using pneumatic tyres far outweigh the minimal cost in time to maintain adequate tyre inflation.

Measuring energy expenditure using heart rate to assess the effects of wheelchair tyre pressure

Objective: To investigate the effects of wheelchair tyre pressure on mechanics and energy and explore the use of heart rate as a measurement of energy expenditure. Design: A single factor repeated measures design was used. Four tyre pressures (100, 75, 50, 25 psi) represented a change of workload. Each subject wheeled at a constant self-selected wheeling velocity for 8 min. A total of four trials were completed with a 10-min rest between trials. Oxygen consumption, heart rate and distance travelled were collected during each trial. Subjects: Three women and 11 men with spinal cord injury. The mean age for the whole group was 34.5 years. The range of lesion level was T4-L1. Results: There was a significant increase is energy expenditure when tyres were deflated to 50 psi from 100 psi. The mean correlation between heart rate and oxygen consumption was 0.74 for all subjects. For the subjects with lesions above T6 and T6 and below the correlations were 0.55 and 0.82, respectively. Conclusions: Tyre pressures below 50% inflation add an additional 25% increase in energy expenditure during wheeling. This could be detected using oxygen consumption or heart rate, as heart rate was shown to have a good correlation with oxygen consumption in the spinal cord injured with lesions below T5. Heart rate does have its limitations and it should only be used to measure within-subject differences.

Effectiveness of a wheelchair skills training program for powered wheelchair users: a randomized controlled trial

OBJECTIVES To test the hypothesis that powered wheelchair users who receive the Wheelchair Skills Training Program (WSTP) improve their wheelchair skills in comparison with a control group that receives standard care, and secondarily to assess goal achievement, satisfaction with training, retention, injury rate, confidence with wheelchair use, and participation. DESIGN Randomized controlled trial. SETTING Rehabilitation centers and communities. PARTICIPANTS Powered wheelchair users (N=116). INTERVENTION Five 30-minute WSTP training sessions. MAIN OUTCOME MEASURES Assessments were done at baseline (t1), posttraining (t2), and 3 months posttraining (t3) using the Wheelchair Skills Test Questionnaire (WST-Q version 4.1), Goal Attainment Score (GAS), Satisfaction Questionnaire, injury rate, Wheelchair Use Confidence Scale for Power Wheelchair Users (WheelCon), and Life Space Assessment (LSA). RESULTS There was no significant t2-t1 difference between the groups for WST-Q capacity scores (P=.600), but the difference for WST-Q performance scores was significant (P=.016) with a relative (t2/t1 × 100%) improvement of the median score for the intervention group of 10.8%. The mean GAS ± SD for the intervention group after training was 92.8%±11.4%, and satisfaction with training was high. The WST-Q gain was not retained at t3. There was no clinically significant difference between the groups in injury rate and no statistically significant differences in WheelCon or LSA scores at t3. CONCLUSIONS Powered wheelchair users who receive formal wheelchair skills training demonstrate modest, transient posttraining improvements in their WST-Q performance scores, have substantial improvements on individualized goals, and are positive about training.

Wheelchair skills training programme for children: A pilot study

AIM Wheelchair skills are not typically provided when a child gets a new wheelchair. The purpose of this prospective pilot study was to determine the effectiveness of a two-day modified Wheelchair Skills Programme 3.2 for children. METHODS Six children (ages 6-19 years) with spinal cord injuries or spina bifida were invited to participate in a two-day wheelchair skills programme provided on subsequent Saturdays. Children were tested before and after training using a modified Wheelchair Skills Test 3.2. To assess for the effect of the programme on participation, the Activity Skills for Kids was used before and one month after training. For a more qualitative reflection, an Impact Questionnaire was given at four months post-training. RESULTS There was a significant (14%) increase in skills based on the Wheelchair Skills Test 3.2. No change in participation was measured with the Activity Skills for Kids. The Impact Questionnaire suggests the skill training allowed participants to do more, with less pain and fatigue post-training. CONCLUSIONS A two-day wheelchair skills programme can potentially improve skill level in children with spinal cord injuries or spina bifida.

Effects of Three-dimensional Assessment on Surgical Correction and on Hook Strategies in Multi-hook Instrumentation for Adolescent Idiopathic Scoliosis

Study Design. A prospective study using intraoperative stereophotogrammetry to analyze change during the correction of scoliosis. Objective. To examine the relation between the number of hooks used during segmental instrumentation and the amount of correction achieved. Summary of Background Data. An intraoperative stereophotogrammetric technique was developed at our center. Vertebral translations and rotations can be measured at several stages during scoliosis surgery. Methods. Thirty‐two patients with right thoracic adolescent idiopathic scoliosis were studied using our stereophotogrammetry technique during surgical correction. Correlations were determined between apical vertebral movements and the hook ratio (number of vertebrae/number of hooks used). Results. Mean curve Cobb angle correction was 66%. Correction occurred in all three planes but primarily along the x and y axes. Scoliotic deformity was corrected by translation of the vertebra along the y axis and rotation about the x; physiologic kyphosis was restored by translation along the x axis and rotation about the y. The plane of maximum deformity as compared with the sagittal plane of the patient corrected from 57° to 25° as an indication of detorsion of the scoliotic deformity. Conclusions. Increasing the number of hooks per vertebral segment significantly enhances the correction of the coronal scoliotic deformity and enhances the z axis derotation, but does not significantly change the reestablishment of the kyphosis, nor does it result in significant elongation of the spine.