Elena M. Gutierrez-Farewik

Does botulinum toxin A improve the walking pattern in children with idiopathic toe-walking?

BackgroundNumerous recommendations have been made for treating idiopathic toe-walking (ITW), but the treatment results have been questioned. The purpose of this study was to investigate whether botulinum toxin A (BTX) improves the walking pattern in ITW as examined with 3-D gait analysis.Participants and methodsA consecutive series of 15 children (aged 5–13 years) were enrolled in the study. The children underwent a 3-D gait analysis prior to treatment with a total of 6 units/kg bodyweight Botox® in the calf muscles and an exercise program. The gait analysis was repeated 3 weeks and 3, 6, and 12 months after treatment. A classification of toe-walking severity was made before treatment and after 12 months. The parents rated the perceived amount of toe-walking prior to treatment and 6 and 12 months after treatment.ResultsEleven children completed the 12-month follow-up. The gait analysis results displayed a significant improvement, indicating decreased plantarflexion angle at initial contact and during swing phase and increased dorsiflexion angle during midstance at all post-treatment testing instances. According to the parents’ perception of toe-walking, 3/11 children followed for 12 months had ceased toe-walking completely, 4/11 decreased toe-walking, and 4/11 continued toe-walking. After 6–12 months, the toe-walking severity classification improved in 9 of the 14 children for whom data could be assessed.ConclusionsA single injection of BTX in combination with an exercise program can improve the walking pattern in children with ITW seen at gait analysis, but the obvious goal of ceasing toe-walking is only occasionally reached.

Gait in children with arthrogryposis multiplex congenita

PurposeLower limb contractures and muscle weakness are common in children with arthrogryposis multiplex congenita (AMC). To enhance or facilitate ambulation, orthoses may be used. The aim of this study was to describe gait pattern among individuals wearing their habitual orthotic devices.MethodsFifteen children with AMC, mean age 12.4 (4.3) years, with some lower limb involvement underwent 3-D gait analysis. Three groups were defined based on orthosis use; Group 1 used knee–ankle–foot orthoses with locked knee joints, Group 2 used ankle–foot orthoses or knee–ankle–foot orthoses with open knee joints and Group 3 used no orthoses.ResultsThe greatest trunk and pelvis movements in all planes and the greatest hip abduction were observed in Group 1, compared to Groups 2 and 3, as well as to the gait laboratory control group. Maximum hip extension was similar in Groups 1 and 2, but in Group 3, there was less hip extension and large deviations from the control data. Lower cadence and walking speed were observed in Group 1 than in Groups 2 and 3. The step length was similar in all groups and also with respect to the gait laboratory reference values.ConclusionsChildren with AMC were subdivided according to orthoses use. Kinematic data as recorded with 3-D gait analysis showed differences among the groups in trunk, pelvis and knee kinematics, and in cadence and walking speed. The step length was similar in all groups and to the gait laboratory reference values, which may be attributable to good hip extension strength in all participants.

Botulinumtoxin A treatment in toddlers with cerebral palsy

Aims:  In this study the aim was to evaluate the effect of botulinum toxin A (BoNT‐A) treatment on muscle tone, contracture development and gait pattern in young children with cerebral palsy (CP).

One year follow-up after operative ankle fractures: A prospective gait analysis study with a multi-segment foot model

Ankle fractures are one of the most common lower limb traumas. Several studies reported short- and long-term post-operative results, mainly determined by radiographic and subjective functional evaluations. Three-dimensional gait analysis with a multi-segment foot model was used in the current study to quantify the inter-segment foot motions in 18 patients 1 year after surgically treated ankle fractures. Data were compared to that from gender- and age-matched healthy controls. The correlations between Olerud/Molander ankle score and kinematics were also evaluated. Patients with ankle fractures showed less plantarflexion and smaller range of motion in the injured talocrural joint, which were believed to be a sign of residual joint stiffness after surgery and immobilization. Moreover, the forefoot segment had smaller sagittal and transverse ranges of motion, less plantarflexion and the hallux segment had less dorsiflexion and smaller sagittal range of motion. The deviations found in the forefoot segment may contribute to the compensation mechanisms of the injured ankle joint. Findings of our study show that gait analysis with a multi-segment foot model provides a quantitative and objective way to perform the dynamic assessment of post-operative ankle fractures, and makes it possible to better understand not only how the injured joint is affected, but also the surrounding joints.

Botulinum Toxin A Does Not Improve the Results of Cast Treatment for Idiopathic Toe-Walking

BACKGROUND There are many treatments for idiopathic toe-walking, including casts with or without injection of botulinum toxin A. Combined treatment with casts and botulinum toxin A has become more common even though there have been few studies of its efficacy and safety problems. Our aims were to conduct a randomized controlled trial to test the hypotheses that combined treatment with casts and botulinum toxin A is more effective than casts alone in reducing toe-walking by patients five to fifteen years of age, and that the treatment effect correlates with the extent of coexisting neuropsychiatric problems. METHODS All patients who had been consecutively admitted to the pediatric orthopaedics department of our institution because of idiopathic toe-walking between November 2005 and April 2010 were considered for inclusion in the study. Forty-seven children constituted the study population. The children were randomized to undergo four weeks of treatment with below-the-knee casts either as the sole intervention or to undergo the cast treatment one to two weeks after receiving injections of botulinum toxin A into the calves. Before treatment and three and twelve months after cast removal, all children underwent three-dimensional (3-D) gait analysis. The severity of the idiopathic toe-walking was classified on the basis of the gait analysis, and the parents rated the time that their child spent on his/her toes during barefoot walking. Passive hip, knee, and ankle motion as well as ankle dorsiflexor strength were measured. Before treatment, all children were evaluated with a screening questionnaire for neuropsychiatric problems. RESULTS No differences were found in any outcome parameter between the groups before treatment or at three or twelve months after cast removal. Several gait-analysis parameters, passive ankle motion, and ankle dorsiflexor strength were improved at both three and twelve months in both groups, even though many children still demonstrated some degree of toe-walking. The treatment outcomes were not correlated with coexisting neuropsychiatric problems. CONCLUSION Adding botulinum toxin-A injections prior to cast treatment for idiopathic toe-walking does not improve the outcome of cast-only treatment.

The effect of subtalar inversion/eversion on the dynamic function of the tibialis anterior, soleus, and gastrocnemius during the stance phase of gait.

The purpose of this study was to determine how gait deviation in one plane (i.e. excessive subtalar inversion/eversion) can affect the dynamic function of the tibialis anterior, gastrocnemius, and soleus to accelerate the subtalar, ankle, knee and hip joints, as well as the body center of mass. Induced acceleration analysis was performed based on a subject-specific three-dimensional linkage model configured by stance phase gait data and driven by one unit of muscle force. Eight healthy adult subjects were examined in gait analysis. The subtalar inversion/eversion was modeled by offsetting up to 20° from the normal subtalar angle while other configurations remained unaltered. This study showed that the gastrocnemius, soleus and tibialis anterior generally functioned as their anatomical definition in normal gait, but counterintuitive function was occasionally found in the bi-articular gastrocnemius. The plantarflexors play important roles in the body support and forward progression. Excessive subtalar eversion was found to enlarge the plantarflexors and tibialis anteriors function. Induced acceleration analysis demonstrated its ability to isolate the contributions of individual muscle to a given factor, and as a means of studying effect of pathological gait on the dynamic muscle functions.

Botulinum Toxin A Does Not Improve the Results of Cast Treatment for Idiopathic Toe-walking: A Randomized Controlled Trial

BACKGROUND There are many treatments for idiopathic toe-walking, including casts with or without injection of botulinum toxin A. Combined treatment with casts and botulinum toxin A has become more common even though there have been few studies of its efficacy and safety problems. Our aims were to conduct a randomized controlled trial to test the hypotheses that combined treatment with casts and botulinum toxin A is more effective than casts alone in reducing toe-walking by patients five to fifteen years of age, and that the treatment effect correlates with the extent of coexisting neuropsychiatric problems. METHODS All patients who had been consecutively admitted to the pediatric orthopaedics department of our institution because of idiopathic toe-walking between November 2005 and April 2010 were considered for inclusion in the study. Forty-seven children constituted the study population. The children were randomized to undergo four weeks of treatment with below-the-knee casts either as the sole intervention or to undergo the cast treatment one to two weeks after receiving injections of botulinum toxin A into the calves. Before treatment and three and twelve months after cast removal, all children underwent three-dimensional (3-D) gait analysis. The severity of the idiopathic toe-walking was classified on the basis of the gait analysis, and the parents rated the time that their child spent on his/her toes during barefoot walking. Passive hip, knee, and ankle motion as well as ankle dorsiflexor strength were measured. Before treatment, all children were evaluated with a screening questionnaire for neuropsychiatric problems. RESULTS No differences were found in any outcome parameter between the groups before treatment or at three or twelve months after cast removal. Several gait-analysis parameters, passive ankle motion, and ankle dorsiflexor strength were improved at both three and twelve months in both groups, even though many children still demonstrated some degree of toe-walking. The treatment outcomes were not correlated with coexisting neuropsychiatric problems. CONCLUSION Adding botulinum toxin-A injections prior to cast treatment for idiopathic toe-walking does not improve the outcome of cast-only treatment.

Kinematic and kinetic analysis of static sitting of patients with neuropathic spine deformity

Wheelchair dependent children with neuropathic and neuromuscular diseases have up to 90% risk for progressive spine deformities. An unbalanced sitting can induce progression of spinal and pelvic deformities. Many current clinical assessment methods of sitting of such patients are semi-quantitative, or questionnaire-based. A 3D movement analysis offers quantitative and objective biomechanical analysis of sitting. The aim was to validate a method to describe quiet sitting and differences between patients and controls as well as to apply the methodology for pre- and post-operative comparison. The analysis was performed on 14 patients and 10 controls. Four patients were retested after spine surgery. Seat load asymmetry was up to 30% in the patient group comparing to maximum 7% in the control group. The asymmetric position of Ground Reaction Force vector between left and right sides was significant. Plumb line of cervical 7th vertebra over sacral 1st was different only in rotation. The location of Common Center of Pressure relative to inter-trochanteric midpoint was more anterior in controls than in patients. Pelvic inclination in patients was smaller, the obliquity and rotation was similar. There were no significant differences between patients and controls of the thorax position. Results with more changes in the seat-loading domain in comparison with posture indicate good postural control compensation of spinal deformity induced disequilibrium despite neuromuscular disease in the background. The comparison of the pelvic obliquity data from kinematics and X-ray showed good correlation. The four patients tested postoperatively improved after surgery.

Influence of heel lifts during standing in children with motor disorders

Heel wedges may influence standing posture but how and to what extent are unknown. Thirty-two children with motor disorders - 16 with arthrogryposis multiplex congenita (AMC) and 16 with cerebral palsy (CP) - and 19 control children underwent a three-dimensional motion analysis. Unassisted standing during 20s with shoes only and with heel lifts of 10, 20 and 30mm heights was recorded in a randomized order. The more weight-bearing limb or the right limb was chosen for analysis. In both the AMC and CP groups, significant changes were seen between various heel lifts in ankle, knee and pelvis, and in the control group in the ankle only. Between orthosis and non-orthosis users significant differences were seen between different heel lift conditions in ankle, knee and trunk in the AMC group and in the ankle in the CP group. Pelvis position changed toward less anterior tilt with increasing heel height, but led to increasing knee flexion in most of the children, except for the AMC Non-Ort group. Children with AMC and CP represent different motor disorders, but the heel wedges had a similar influence on pelvis, hip and knee positions in all children with CP and in the AMC orthosis users. A challenge is to apply heel heights adequate to each individuals orthopaedic and neurologic conditions to improve biomechanical alignment with respect to all body segments.

Computation of ground reaction force using Zero Moment Point.

Motion analysis is a common clinical assessment and research tool that uses a camera system or motion sensors and force plates to collect kinematic and kinetic information of a subject performing an activity of interest. The use of force plates can be challenging and sometimes even impossible. Over the past decade, several computational methods have been developed that aim to preclude the use of force plates. Useful in particular for predictive simulations, where a new motion or change in control strategy inherently means different external contact loads. These methods, however, often depend on prior knowledge of common observed ground reaction force (GRF) patterns, are computationally expensive, or difficult to implement. In this study, we evaluated the use of the Zero Moment Point as a computationally inexpensive tool to obtain the GRFs for normal human gait. The method was applied on ten healthy subjects walking in a motion analysis laboratory and predicted GRFs are evaluated against the simultaneously measured force plate data. Apart from the antero-posterior forces, GRFs are well-predicted and errors fall within the error ranges from other published methods. Joint extension moments were underestimated at the ankle and hip but overestimated at the knee, attributable to the observed discrepancy in the predicted application points of the GRFs. The computationally inexpensive method evaluated in this study can reasonably well predict the GRFs for normal human gait without using prior knowledge of common gait kinetics.