Britta K. Krautwurst

Reduction in primary genu recurvatum gait after aponeurotic calf muscle lengthening during multilevel surgery.

Knee hyperextension (genu recurvatum, GR) is often seen in children with bilateral spastic cerebral palsy (CP). Primary GR appears essential without previous treatment. As equinus deformity is suspected to be one of the main factors evoking primary GR, the purpose of this study was to determine whether lengthening the calf muscles to decrease equinus would decrease coexisting GR in children with bilateral spastic CP. In a retrospective study, 19 CP patients with primary GR (mean age: 9.4 years, 13 male, 6 female, 26 involved limbs) in whom an aponeurotic calf muscle lengthening procedure was performed during single-event multilevel surgery were included and investigated using three-dimensional gait analysis before and at a mean follow-up of 14 months after the procedure according to a standardized protocol. After calf muscle lengthening, a significant improvement in ankle dorsiflexion (9.5°) and a significant reduction (10.5°) in knee hyperextension (p<0.001) were found during mid-stance of the gait cycle. Six limbs (23%) showed no improvement concerning knee hyperextension and were designated as nonresponders. In these patients no significant improvement in ankle dorsiflexion was found after surgery either. Improvement in ankle dorsiflexion and reduction in knee hyperextension in stance phase correlated significantly (r=0.46; p=0.019). These findings indicate that equinus deformity is a Major underlying factor in Primary GR and that calf muscle lengthening can effectively reduce GR in patients with CP.

The impact of walking devices on kinematics in patients with spastic bilateral cerebral palsy.

Increased anterior pelvic and trunk tilt is a common finding in patients with bilateral cerebral palsy especially during walking with assistive devices. As previous studies demonstrate various gait alterations when using assistive devices, the assessment of surgical interventions may be biased when the patients become independent of (or dependent on) assistive devices after therapy. Furthermore, some of these patients in fact are able to walk without devices even though in daily life they prefer to use them. Consequently, for such patients the classification into GMFCS level II or III may be ambiguous. The specific aim of this study was therefore to assess the influence of the use of forearm crutches and posterior walker during walking and to set this influence in relation to outcome effects of surgical intervention studies. 26 ambulatory patients with spastic bilateral CP (GMFCS II-III) were included who underwent 3D gait analysis. All patients used forearm crutches or posterior walkers in everyday life even though they were able to walk without assistive devices for short distances. Independent of the type of assistive devices, the patients walk on average with more anterior trunk tilt and pelvic tilt (7°±6° and 3°±2°) and with a maximum ankle dorsiflexion decreased by 2° (±3°) when walking with assistive devices, enhancing the mal-positioning present without device. Oppositely, the knees on average are more extended by 6° (±4°) when using the assistive devices. These effects have to be taken into account when assessing gait patterns or when monitoring the outcome after intervention as assistive devices may partially hide or exaggerate therapeutic effects.

How do children with bilateral spastic cerebral palsy manage walking on inclines

BACKGROUND Walking on inclined surfaces is an everyday task, which challenges stability and propulsion even in healthy adults. Children with cerebral palsy adapt similarly to inclines like healthy children do. However, how stability and propulsion in these subjects are influenced by different inclines remained unaddressed as of yet. RESEARCH QUESTION The aim was to examine the feeling of safety, stability and propulsion of children with cerebral palsy when walking on inclines to gain insight into the challenges they might face on these conditions. METHODS Eighteen children with bilateral spastic cerebral palsy with gross motor function classification scale level I and II and nineteen healthy children underwent instrumented 3D gait analysis on level ground and on a 5° and a 10° incline. A mixed linear model was used to draw between and within group comparisons. RESULTS Reduced lateral trunk sway, a relative lengthening of the lower limb at initial contact and a controlled walking speed were employed during downhill gait compared to level walking. Patients showed an increased sagittal ROM of trunk (3-4°) and pelvis (2-3°) and a decreased sagittal knee ROM (13°) compared to the typically developed children. During uphill gait, an insufficient increase of push-off power at the ankle (increase by 0.48 W/kg) was noted in children with CP, which appeared to lead to particularly shorter strides (about 0.1 m) in patients compared to healthy children (increase by 1.32 W/kg). SIGNIFICANCE Depending on inclination angle, children with cerebral palsy managed to walk on inclines in a controlled manner. The steeper the incline, the more the gait appeared to be affected: decreased feeling of safety, increased need for stabilising mechanisms for downhill gait and less sufficient uphill propulsion were seen. Helping these patients to attain better control during downhill gait and strengthening uphill gait mechanisms may support their participation in everyday life.

Rasterstereographic Analysis of Lateral Shift in Patients with Lumbar Disc Herniation: A Case Control Study

Objective Detection of a lateral shift (LS) in patients with diagnosed disc herniation compared to healthy controls. Summary of Background Data A specific lateral shift (LS) pattern is observed in patients with disc herniation and low back pain, as shown in earlier studies. Methods Rasterstereography (RS) was used to investigate the LS. Thirty-nine patients with lumbar disc herniation diagnosed by radiological assessment and low back pain and/or leg pain (mean age 48.2 years, mean BMI 28.5, 28 males and 11 females) and 36 healthy controls (mean age 47.4 years, mean BMI 25.7, 25 males and 11 females) were analysed. LS, pelvic tilt, pelvic inclination, lordotic angle, and trunk torsion were assessed. Results The patient group showed a nonsignificant increase in LS, that is, 5.6 mm compared to the healthy controls with 5.0 mm (p = 0.693). However, significant differences were found between groups regarding pelvic tilt in degrees (patients 5.9°, healthy controls 2.0°; p = 0.016), trunk torsion (patients 7.5°, controls 4.5°; p = 0.017), and lordotic angle (patients 27.5°, healthy controls 32.7°; p = 0.022). The correlation between pain intensity and the FFbH-R amounted 0.804 (p = < 0.01), and that between pain intensity and the pain disability index was 0.785 (p < 0.01). Discussion Although some studies have illustrated LS with disc herniation and low back pain, the present findings demonstrate no significant increase in LS in the patient group compared to healthy controls. Conclusion The patients with lumbar disc herniation did not demonstrate an increased LS compared to healthy controls. Other parameters like pelvic tilt and inclination seemed to be more suitable to identify changes in posture measured by RS in patients with low back pain or disc herniation.

What is the price for the Duchenne gait pattern in patients with cerebral palsy

Duchenne gait is characterized by trunk lean towards the affected stance limb with the pelvis stable or elevated on the swinging limb side during single limb stance phase. We assessed the relationship between hip abduction moments and trunk kinetics in patients with cerebral palsy showing excessive lateral trunk motion. Data of 18 subjects with bilateral spastic cerebral palsy (CP) and 20 aged matched typically developing subjects (TD) were collected retrospectively. Criteria for patient selection were barefoot walking without aid presenting with excessive lateral trunk motion. Subjects had been monitored by conventional 3D gait analysis of the lower extremity including four markers for monitoring trunk motion. Post-hoc, a generic musculoskeletal full body model (OpenSim 3.3) assuming a rigid trunk articulated to the pelvis by a single ball joint was applied for analyzing joint kinematics and kinetics of the lower limb joints including this spine joint. Joint angle ranges of motion, maximum joint moments and powers in the frontal plane as well as mechanical work were calculated and averaged within groups showing prominent differences between groups in all parameters. To the best of our knowledge, this is the first work explicitly looking into the kinetics of Duchenne gait in patients with CP, clinically known as compensation for unloading hip abductor muscles. The results show that excessive lateral trunk motion may indeed be an extremely effective compensation mechanism to unload the hip abductors in single limb stance but for the price of a drastic increase in demand on trunk muscle effort and work.

Three-dimensional evaluation of heel raise test in pediatric planovalgus feet and normal feet

Planovalgus foot is a common pediatric deformity which may be associated with pain. To evaluate flexibility of the foot, the heel raise test is used. During this test the arch and hindfoot are assessed. Several studies have described planovalgus foot based on 3D gait and standing analysis. However, no studies have evaluated foot flexibility during heel raise using an objective 3D analysis. Therefore, the purpose of this study is to evaluate the flexibility of planovalgus feet during the heel raise test using an objective 3D assessment and to determine whether any hypotheses can be generated about potential differences between painful and painless flexible planovalgus feet and reference feet. Here, 3D foot analysis was conducted in 33 children (7 reference feet, 16 painless, and 10 painful flexible planovalgus feet) during the heel raise test. To identify the characteristics of planovalgus foot, the concept of 3D projection angles was used as introduced in the Heidelberg Foot Measurement Method (HFMM), with a modified marker set. All feet showed dynamic movements of the medial arch and hindfoot from valgus to varus position during heel raise. Reference feet had the smallest range of motion, perhaps due to joint stability and absence of foot deformity. Painful and painless flexible planovalgus feet demonstrated similar movements. No significant differences were found between the painful and painless groups. However, the kinematics of the pain group seemed to differ more from those of the reference group than did kinematics of the painless group. This assessment is a new, practical, and objective method to measure the flexibility of small childrens feet.