Fiona Dobson

Measures of physical performance assessments: Self-Paced Walk Test (SPWT), Stair Climb Test (SCT), Six-Minute Walk Test (6MWT), Chair Stand Test (CST), Timed Up & Go (TUG), Sock Test, Lift and Carry Test (LCT), and Car Task.

In this review, clinical physical performance measures (PPMs) that relate directly to people with lower extremity osteoarthritis (OA) (1), yet are also relevant for other rheumatic conditions that affect the lower extremity, are evaluated. This information is complementary and an update to some of the measures of adult general performance presented in the special issue of Arthritis Care & Research in 2003 (2). In the current review, PPMs are defined as clinician-observed measures of physical function that assess a task that can be classified as “activities” using the World Health Organization International Classification of Functioning, Disability and Health (ICF) model (3). They do not include measures that are specific tests of body structure, body function, or impairments, e.g., specific measures of strength or balance. Physical function is related to “the ability to move around” (4) and “the ability to perform daily activities” (5) and is assessed directly by an observer while the activity is being performed by an individual, usually by timing, counting, or distance measures. PPMs measure what an individual can do rather than what the individual perceives they can do as in self-reported functional measures (5). The selection of PPMs for this review was based on the following criteria: 1) clinical (field) tests: PPMs were selected if they were readily available, required portable or no equipment, and could be conducted within the clinical setting; 2) relevant to core activities commonly impaired in people with OA: a range of PPMs was selected to reflect the ICF activities most relevant to individuals with lower extremity OA, including walking and moving (ICF d450– 69), changing and maintaining body position (ICF d410– 29), climbing (ICF d4551), and carrying, moving, and handling objects (ICF d430–49); 3) current trends: PPMs that have been included in a performance battery for lower extremity OA were targeted to reflect current trends and recommendations in recent literature (a performance battery is a composite of a number of individual PPMs grouped together); and 4) most commonly cited: PPMs for individuals with OA that were most commonly cited in a literature search were given priority over those less frequently cited. A computerized literature search using Medline, CINAHL, ISI Web of Science, Scopus, and Cochrane was performed. Key terms were mapped to medical subject headings terms: osteoarthritis (hip and knee), task performance and analysis, observation, physical examination, walking or mobility limitations, physical fitness, physical functioning or disability evaluation, and performancebased measures.

Does botulinum toxin a combined with bracing prevent hip displacement in children with cerebral palsy and "hips at risk"? A randomized, controlled trial.

BACKGROUND Cerebral palsy is the most common cause of childhood physical disability in developed countries, affecting two children per 1000 live births. Hip displacement affects about one-third of children with cerebral palsy and may result in pain, deformity, and impaired function. The prevention of hip displacement has not been studied in a randomized trial as far as we know. METHODS A randomized, controlled trial was conducted to examine the effect of intramuscular injections of botulinum toxin A combined with use of a variable hip abduction brace on the progression of hip displacement in children with cerebral palsy. The patients in the treatment group received injections of botulinum toxin A to the adductor and hamstring muscles every six months for three years and were prescribed a hip abduction brace to be worn for six hours per day. In the control group, no hip bracing was used nor were injections performed. The primary outcome measure was hip displacement from the acetabulum as determined by serial measurements of the migration percentage. RESULTS Ninety children with bilateral cerebral palsy and so-called hips at risk (a migration percentage of >10% but <40%) were entered into the study. Fifty-nine patients were boys, and the mean age was three years. Progressive hip displacement, as determined by serial measurements of the migration percentage, was found in both the treatment and control groups. The rate of hip displacement was reduced in the treatment group by 1.4% per year (95% confidence interval, -0.6% to 3.4%; p = 0.16) when weighted for the uncertainty in rates due to the differing numbers of migration percentage measurements per subject. CONCLUSIONS There may be a small treatment benefit for the combined intervention of intramuscular injection of botulinum toxin A and abduction hip bracing in the management of spastic hip displacement in children with cerebral palsy. However, progressive hip displacement continued to occur in the treatment group, and our data do not support recommending this treatment.

Hip surveillance in children with cerebral palsy: IMPACT ON THE SURGICAL MANAGEMENT OF SPASTIC HIP DISEASE

We studied prospectively the impact of a hip surveillance clinic on the management of spastic hip disease in children with cerebral palsy in a tertiary referral centre. Using a combination of primary clinical and secondary radiological screening we were able to detect spastic hip disease at an early stage in most children and to offer early surgical intervention. The principal effect on surgical practice was that more preventive surgery was carried out at a younger age and at a more appropriate stage of the disease. The need for reconstructive surgery has decreased and that for salvage surgery has been eliminated. Displacement of the hip in children with cerebral palsy meets specific criteria for a screening programme. We recommend that hip surveillance should become part of the routine management of children with cerebral palsy. The hips should be examined radiologically at 18 months of age in all children with bilateral cerebral palsy and at six- to 12-monthly intervals thereafter. A co-ordinated approach by orthopaedic surgeons and physiotherapists may be the key to successful implementation of this screening programme.

Single-event multilevel surgery for children with cerebral palsy: a systematic review

Aim  To conduct a systematic review of single‐event multilevel surgery (SEMLS) for children with cerebral palsy, with the aim of evaluating the quality of the evidence and developing recommendations for future research.

A randomized controlled trial of the impact of therapeutic horse riding on the quality of life, health, and function of children with cerebral palsy

This randomized controlled trial examined whether therapeutic horse riding has a clinically significant impact on the physical function, health and quality of life (QoL) of children with cerebral palsy (CP). Ninety‐nine children aged 4 to 12 years with no prior horse riding experience and various levels of impairment (Gross Motor Function Classification System Levels I−III) were randomized to intervention (10wks therapeutic programme; 26 males, 24 females; mean age 7y 8mo [SD 2y 5mo] or control (usual activities, 27 males, 22 females; mean age 8y 2mo [SD 2y 6mo]). Pre‐ and post‐measures were completed by 72 families (35 intervention and 37 control). Children’s gross motor function (Gross Motor Function Measure [GMFM]), health status (Child Health Questionnaire [CHQ]), and QoL (CP QoL‐Child, KIDSCREEN) were assessed by parents and QoL was assessed by children before and after the 10‐week study period. On analysis of covariance, there was no statistically significant difference in GMFM, CP QoL‐Child (parent report and child self‐report), and CHQ scores (except family cohesion) between the intervention and control group after the 10‐week study period, but there was weak evidence of a difference for KIDSCREEN (parent report). This study suggests that therapeutic horse riding does not have a clinically significant impact on children with CP. However, a smaller effect cannot be ruled out and the absence of evidence might be explained by a lack of sensitivity of the instruments since the QoL and health measures have not yet been demonstrated to be sensitive to change for children with CP.

Proximal femoral geometry in cerebral palsy A POPULATION-BASED CROSS-SECTIONAL STUDY

There is much debate about the nature and extent of deformities in the proximal femur in children with cerebral palsy. Most authorities accept that increased femoral anteversion is common, but its incidence, severity and clinical significance are less clear. Coxa valga is more controversial and many authorities state that it is a radiological artefact rather than a true deformity. We measured femoral anteversion clinically and the neck-shaft angle radiologically in 292 children with cerebral palsy. This represented 78% of a large, population-based cohort of children with cerebral palsy which included all motor types, topographical distributions and functional levels as determined by the gross motor function classification system. The mean femoral neck anteversion was 36.5 degrees (11 degrees to 67.5 degrees) and the mean neck-shaft angle 147.5 degrees (130 degrees to 178 degrees). These were both increased compared with values in normally developing children. The mean femoral neck anteversion was 30.4 degrees (11 degrees to 50 degrees) at gross motor function classification system level I, 35.5 degrees (8 degrees to 65 degrees ) at level II and then plateaued at approximately 40.0 degrees (25 degrees to 67.5 degrees) at levels III, IV and V. The mean neck-shaft angle increased in a step-wise manner from 135.9 degrees (130 degrees to 145 degrees) at gross motor function classification system level I to 163.0 degrees (151 degrees to 178 degrees) at level V. The migration percentage increased in a similar pattern and was closely related to femoral deformity. Based on these findings we believe that displacement of the hip in patients with cerebral palsy can be explained mainly by the abnormal shape of the proximal femur, as a result of delayed walking, limited walking or inability to walk. This has clinical implications for the management of hip displacement in children with cerebral palsy.

Hip displacement in spastic cerebral palsy: Repeatability of radiologic measurement

Radiologic measures of migration percentage (MP) and acetabular index (AI) taken from plain radiographs of the pelvis are the most commonly used tools for determining hip displacement and management options in children with cerebral palsy and spastic hip disease. This study determined interrater and intrarater reliability of MP and AI on pelvic radiographs chosen to represent a wide range of age (11 months to 8 years 5 months), MP (0%–56%), and AI (9°–33°). The study demonstrated that an experienced rater would be expected to measure MP on a single radiograph to within ±5.8% of the true value and a change in MP between two radiographs taken at different times to within ±8.3% of the true value. Similarly for AI, the measurement error for a typical rater would be within ±2.6°on a single reading and ±3.7° if recording change between two occasions. The authors believe that the results indicating true change are acceptable in clinical practice, provided treatment decisions are based on a series of radiographs taken at 6-month intervals, methods and training are standardized, and consistent raters are used.

The effect of botulinum toxin type A and a variable hip abduction orthosis on gross motor function: a randomized controlled trial.

Hip displacement is the second most common deformity after equinus in children with cerebral palsy (CP), and may result in dislocation, pain, fixed deformity and loss of function. We studied the combined effects of intramuscular injections of botulinum toxin type A (BTX‐A) to the adductors and hamstrings and a variable hip abduction orthosis (SWASH), on gross motor function, hip displacement and progression to surgery, in a randomized clinical trial. Thirty‐nine children, with bilateral spastic cerebral palsy, and mean age 3 years + 2 months (range 1 year + 7 months–4 years +10 months) entered the trial. Gross Motor Function Classification System (GMFCS) levels were as follows: one child was level II, 11 were level III, 13 were level IV and 14 were level V. After concealed randomization, 20 were allocated to the control group and 19 to the intervention group. Thirty‐five children completed the follow up at 1 year. The novel intervention group received up to 4.0 U BOTOX®/kg/muscle, 16 U/kg/body weight every 6 months plus the use of a SWASH brace. The control group received clinical best practice comprising physiotherapy but no hip abduction bracing. Both groups showed improvements in total Gross Motor Function Measure (GMFM) score [mean 6.0% BTX‐A group; 6.1% Control; 95% CI – 6.7, 6.5 (NS)], however, there was no additional treatment effect for the study group. There were similar improvements on GMFM goal scores and GMFM‐66 scores, but again no additional treatment effect was observed. Multiple regression of change in total GMFM by GMFCS classification for each group showed greater improvement in the total scores from baseline in the BTX‐A/SWASH treated group than the control group. In the first year, nine children (two in the intervention group and seven in the control group) required soft tissue surgery because of progressive hip migration in excess of 40%. A longer‐term follow up of a larger cohort may be required to determine the effect of the combined treatment on hip displacement.

Effects of rehabilitative interventions on pain, function and physical impairments in people with hand osteoarthritis: a systematic review

IntroductionHand osteoarthritis (OA) is associated with pain, reduced grip strength, loss of range of motion and joint stiffness leading to impaired hand function and difficulty with daily activities. The effectiveness of different rehabilitation interventions on specific treatment goals has not yet been fully explored. The objective of this systematic review is to provide evidence based knowledge on the treatment effects of different rehabilitation interventions for specific treatment goals for hand OA.MethodsA computerized literature search of Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ISI Web of Science, the Physiotherapy Evidence Database (PEDro) and SCOPUS was performed. Studies that had an evidence level of 2b or higher and that compared a rehabilitation intervention with a control group and assessed at least one of the following outcome measures - pain, physical hand function or other measures of hand impairment - were included. The eligibility and methodological quality of trials were systematically assessed by two independent reviewers using the PEDro scale. Treatment effects were calculated using standardized mean difference and 95% confidence intervals.ResultsTen studies, of which six were of higher quality (PEDro score >6), were included. The rehabilitation techniques reviewed included three studies on exercise, two studies each on laser and heat, and one study each on splints, massage and acupuncture. One higher quality trial showed a large positive effect of 12-month use of a night splint on hand pain, function, strength and range of motion. Exercise had no effect on hand pain or function although it may be able to improve hand strength. Low level laser therapy may be useful for improving range of motion. No rehabilitation interventions were found to improve stiffness.ConclusionsThere is emerging high quality evidence to support that rehabilitation interventions can offer significant benefits to individuals with hand OA. A summary of the higher quality evidence is provided to assist with clinical decision making based on current evidence. Further high-quality research is needed concerning the effects of rehabilitation interventions on specific treatment goals for hand OA.

Exercise in osteoarthritis: Moving from prescription to adherence

Exercise is recommended for the management of osteoarthritis (OA) in all clinical guidelines irrespective of disease severity, pain levels, and functional status. For knee OA, evidence supports the benefits of various types of exercise for improving pain and function in the short term. However, there is much less research investigating the effects of exercise in patients with OA at other joints such as the hip and hand. It is important to note that while the magnitude of exercise benefits may be considered small to moderate, these effects are comparable to reported estimates for simple analgesics and oral nonsteroidal anti-inflammatory drugs for OA pain but exercise has much fewer side effects. Exercise prescription should be individualized based on assessment findings and be patient centered involving shared decision making between the patient and clinician. Given that patient adherence to exercise declines over time, appropriate attention should be pain as reduced adherence attenuates the benefits of exercise. Given this, barriers and facilitators to exercise should be identified and strategies to maximize long-term adherence to exercise implemented.