Jacques Riad

Bilateral slipped capital femoral epiphysis: predictive factors for contralateral slip.

The primary goal in treatment of slipped capital femoral epiphysis (SCFE) is to prevent further slip by stabilizing the physis. Debate exists concerning prophylactic fixation of the uninvolved hip at presentation. Our goal was to determine predictive factors for a contralateral slip after presentation with a unilateral SCFE. Ninety patients with SCFE and complete radiographs were followed up until the bilateral closure of the proximal femoral physis. Chronological age at presentation, sex, and race were recorded. Open or closed triradiate cartilage was recorded, and a modified Oxford bone age assessment was performed. Twenty patients (22%) had bilateral SCFE at presentation, and 70 patients (78%) were unilateral. Of these 70 patients, 16 (23%) later developed a contralateral SCFE. Analysis revealed that chronological age was the only significant (P = 0.010) predictor for developing a contralateral slip. All girls younger than 10 years and all boys younger than 12 years who presented with unilateral SCFE developed a contralateral slip. Twenty-five percent of girls younger than 12 years and 37% of boys younger than 14 years developed a contralateral slip. No girl older than 13 years and no boy older than 14 years developed a contralateral slip in our series. Surgical complications were infrequent and isolated to the side of the initial SCFE. Chronological age is a predictor for a contralateral slip in patients presenting with a unilateral SCFE. The authors recommend that all girls younger than 10 years and all boys younger than 12 years presenting with unilateral SCFE should undergo strong consideration for prophylactic screw fixation on the contralateral side. In older age groups, prophylactic treatment may be considered on a case-by-case basis.

Arm posture score and arm movement during walking: A comprehensive assessment in spastic hemiplegic cerebral palsy

Patients with hemiplegic cerebral palsy often have noticeably deviant arm posture and decreased arm movement. Here we develop a comprehensive assessment method for the upper extremity during walking. Arm posture score (APS), deviation of shoulder flexion/extension, shoulder abduction/adduction, elbow flexion/extension and wrist flexion/extension were calculated from three-dimensional gait analysis. The APS is the root mean square deviation from normal, similar to Bakers Gait Profile Score (GPS) [1]. The total range of motion (ROM) was defined as the difference between the maximum and minimum position in the gait cycle for each variable. The arm symmetry, arm posture index (API) was calculated by dividing the APS on the hemiplegic side by that on the non-involved side, and the range of motion index (ROMI) by dividing the ROM on the hemiplegic side by that on the non-involved side. Using the APS, two groups were defined. Group 1 had minor deviations, with an APS under 9.0 and a mean of 6.0 (95% CI 5.0-7.0). Group 2 had more pronounced deviations, with an APS over 9.0 and a mean of 13.1 (CI 10.8-15.5) (p=0.000). Total ROM was 60.6 in group 1 and 46.2 in group 2 (p=0.031). API was 0.89 in group 1 and 1.70 in group 2 (p<0.001). ROMI was 1.15 in group 1 and 0.69 in group 2 (p=0.003). APS describes the amount of deviation, ROM provides additional information on movement pattern and the indices the symmetry. These comprehensive objective and dynamic measurements of upper extremity abnormality can be useful in following natural progression, evaluating treatment and making prognoses in several categories of patients.

Classification of spastic hemiplegic cerebral palsy in children.

Background: The Winter classification of spastic hemiplegic cerebral palsy (CP) is based on sagittal kinematic data from 3-dimensional gait analysis used in preoperative decision making and postoperative evaluation. Our goal was to investigate how well children with spastic hemiplegic CP can be classified using Winter criteria. Second, we assessed if patients move between groups over time and/or with surgical intervention. Methods: One hundred twelve patients with spastic hemiplegic CP with a mean age of 8.1 years were included. Medical records and the full gait analysis data were reviewed. Patients were classified using Winter criteria, and an independent sample t test was used to compare groups. Results: We found 26 patients (23%) that could not be classified according to Winter criteria. We defined these patients as group 0. This group showed the least deviation from normal values. Each of the 5 groups in our study showed a higher mean velocity of gait and were younger than any of the groups from the Winter study. In regard to rotational alignment, kinetic variables, and, to a certain extent, muscle tone, group 0 showed the least deviation from normal values; however, most differences were subtle. When reclassifying patients after a mean of 3 years, 8 of 15 had deteriorated in the nonsurgical group, moving to a higher numbered group, whereas 19 of 31 surgically treated patients had improved. Conclusions: The Winter classification failed to classify 23% (26/112) of our spastic hemiplegic CP children. We suggest that the classification be complemented with the less involved group 0. In this way, all patients can be classified, and thus, treatment plans can be established for all patients. The classification can be divided into ankle, knee, and hip joint involvement. The ankle involvement can be further divided into 3 separate groups. Treating physicians should be aware of the possibility that patients may move into another classification group over time. Level of Evidence: Diagnostic level 4. See instructions to authors for a complete description of levels of evidence.

Arm posturing during walking in children with spastic hemiplegic cerebral palsy.

Elbow flexion in hemiplegic cerebral palsy causes not only a functional impairment but is also a cosmetic concern. We report on the natural history of arm positioning during walking at different ages. One hundred seventy-five children (mean age ± SD, 9.2 ± 4.1 years) were assessed by using 3-dimensional gait analysis. The results showed a significant spontaneous decrease of elbow flexion on the hemiplegic side with increasing age (P = 0.001) and no change on the noninvolved side. The elbow extension significantly increased on the hemiplegic side (P = 0.017) and on the noninvolved side (P = 0.012). The range of motion did not improve significantly on the hemiplegic side, but did on the noninvolved side (P = 0.003). Inasmuch as the hemiplegic side starts out with more flexion at a young age compared with the noninvolved side, the improvement in extension is not as great as on the noninvolved side, and there is no marked gain in range of motion. A decreased variability was noted, measured as SDs of the mean elbow flexion, although it was only significant on the noninvolved side (P = 0.008). Comparing a subgroup of 10 patients who had surgical treatment involving the lengthening of the elbow flexors with a nonoperative group of 59 patients, we found that surgery did not contribute to a better positioning of the arm nor did it normalize the movement pattern while walking. Surgical treatment has been proposed to improve the function and the appearance of the posturing arm in hemiplegic cerebral palsy; however, improvement might be expected spontaneously, and the indication and timing of surgical intervention is not clear.

Do movement deviations influence self-esteem and sense of coherence in mild unilateral cerebral palsy?

Background: Individuals with unilateral cerebral palsy (CP) are often physically high functioning. Despite the mildness of the impairment, the movement deviations during walking are often noticeably deviant. In the arm, increased muscle tone causes posturing and decreased motion. In the lower extremity, gait deviations mainly involve the foot and ankle. The deviations often become more apparent with transitions between movements and during rapid movement but also when the person is emotionally affected. Arm posturing and gait deviations may be perceived as cosmetic and social impediments when the individual enters adolescence and becomes more self-conscious. The aim was to study the influence of movement deviations in the upper and lower extremity during walking, on self-esteem, and sense of coherence (SOC) in teenagers and young adults with mild unilateral CP. Methods: Three-dimensional gait analysis was performed with an 8-camera system. Movement deviations of the lower extremity, the Gait Profile Score (GPS) and of the upper extremity, and the Arm Posturing Score (APS) were calculated. Self-reported questionnaires “I think I am” measuring self-esteem and SOC were used. Results: Forty-four patients with a mean age of 17.6 years (range, 13.0 to 24.0 y), 22 females and 22 males, and 15 sex-matched and age-matched controls participated in the study. Forty-two patients were classified as Gross motor function classification scale (GMFCS) I and 2 as GMFCS II. Patients were rated with lower self-esteem than controls (mean, 63.4 vs. 84.7; P=0.025). The SOC assessments revealed no difference. The GPS and APS was higher in patients (6.9 vs. 4.1; P<0.001) and (mean, 10.5 vs. 5.7; P<0.001), respectively. The APS correlated with both self-esteem (coefficient −0.397; P=0.001) and SOC (coefficient −0.375; P=0.05). No correlations were found with the GPS. Conclusions Although physically high functioning, movement deviations in teenagers and young adults with mild unilateral CP are correlated with lower self-esteem. This is more pronounced with increased arm movement deviation and should be considered when evaluating these individuals. Level of Evidence: Prospective cross-sectional study. Level III.

Longitudinal study of normal hip development by ultrasound.

In the management of a newborns hips, ultrasonography has proven to be useful. The progression of measurements at different ages in normal hips has not been thoroughly investigated. The purpose of this prospective study was to assess the longitudinal development of clinically stable hips. Forty newborns (80 hips) were assessed by ultrasonography at birth and at 6 and 12 weeks of age. Femoral head coverage (FHC), alpha angles, and beta angles were measured. The results showed a significant change in values between the three points in time for all measurements (P < 0.001). The mean FHC progressed from 58.4% to 65.6% to 69.3%, the mean alpha angle from 70.2° to 76.8° to 80.3°, and the mean beta angle from 52.1° to 45.7° to 42.9°. In clinically stable hips, the FHC and alpha and beta angles change significantly over time; therefore, it is important to consider the childs age when interpreting ultrasound images.

Three-Dimensional Gait Analysis Following Achilles Tendon Rupture With Nonsurgical Treatment Reveals Long-Term Deficiencies in Muscle Strength and Function

Background: Precise long-term assessment of movement and physical function following Achilles tendon rupture is required for the development and evaluation of treatment, including different regimens of physical therapy. Purpose: To assess intermediate-term (<10 years by conventional thinking) objective measures of physical function following Achilles tendon rupture treated nonsurgically and to compare these with self-reported measures of physical function. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Two to 5 years after Achilles tendon rupture, 9 women and 43 men (mean age, 49.2 years; range, 26-68 years) were assessed by physical examination, performance of 1-legged jumps, and 3-dimensional gait analysis (including calculation of muscle work). Self-reported scores for foot function (Achilles tendon rupture score) and level of physical activity were collected. Twenty age- and sex-matched controls were assessed in the same manner. Results: Physical examination of patients with the knee extended revealed 11.1° of dorsiflexion on the injured side and 9.2° on the uninjured side (P = .020), indicating gastrocnemius muscle lengthening. The 1-legged jump distance was shorter on the injured side (89.5 vs 96.2 cm; P < .001). Gait analysis showed higher peak dorsiflexion (14.3° vs 13.3°; P = .016) and lower concentric (positive) plantar flexor work (16.6 vs 19.9 J/kg; P = .001) in the ankle on the uninjured side. At the same time, eccentric (negative) dorsiflexor work was higher on the injured side (13.2 vs 11.9 J/kg; P = .010). Self-perceived foot function and physical activity were lower in patients than in healthy controls (mean Achilles tendon rupture score, 78.6 and 99.8, respectively). Conclusion: Nonsurgically treated patients with Achilles tendon rupture showed signs of both anatomic and functional lengthening of the tendon. Attenuated muscle strength and function were present during walking as long as 2 to 5 years after rupture, as determined by 3-dimensional gait analysis. More extensive future studies involving patients having both surgical and nonsurgical treatment could provide additional valuable information.

Movement deviation and asymmetry assessment with three dimensional gait analysis of both upper- and lower extremity results in four different clinical relevant subgroups in unilateral cerebral palsy

BACKGROUND In unilateral cerebral palsy, movement pattern can be difficult to define and quantify. The aim was to assess the degree of deviation and asymmetry in upper and lower extremities during walking. METHODS Forty-seven patients, 45 Gross Motor Function Classification Scale (GMFCS) I and 2 patients GMFCS II, mean age 17.1 years (range 13.1 to 24.0) and 15 matched controls were evaluated. Gait profile score (GPS) and arm posture score (APS) were calculated from three-dimensional gait analysis (GA). Asymmetry was the calculated difference in deviation between affected and unaffected sides. FINDINGS The GPS was significantly increased compared to the control group on the affected side (6.93 (2.08) versus 4.23 (1.11) degrees) and on the unaffected side (6.67 (2.14)). The APS was also significantly increased on the affected side (10.39 (5.01) versus 5.52 (1.71) degrees) and on the unaffected side (7.13 (2.23)). The lower extremity asymmetry increased (significantly) in comparison with the control group (7.89 (3.82) versus 3.90 (1.01)) and correspondingly in the upper extremity (9.75 (4.62) versus 5.72 (1.84)). The GPS was not different between affected and unaffected sides, however the APS was different (statistically significant). INTERPRETATION We calculated deviation and asymmetry of movement during walking in unilateral CP, identifying four important clinical groups: close to normal, deviations mainly in the leg, deviations mainly in the arm and those with deviation in the arm and leg. This method can be applied to any patient group, and aid in diagnosing, planning treatment, and prognosis.

Does footprint and foot progression matter for ankle power generation in spastic hemiplegic cerebral palsy

OBJECTIVES We investigated how foot pressure pattern and foot progression relate to power generation from the ankle joint in children with spastic hemiplegic cerebral palsy (CP). METHODS The study included 35 children (13 girls, 22 boys; mean age 8.8 years; range 4 to 19.8) with CP, all having independent ambulation. The children underwent three-dimensional gait analysis and a set of pedobarographic data were obtained. The pedobarographs were analyzed by dividing the foot into five segments. RESULTS The mean power generation from the ankle was 7.6 watts/kg on the hemiplegic side, and 15.9 watts/kg on the uninvolved side (p=0.000). Based on the pedobarographic data, hemiplegic feet exhibited significantly less heel pressure/impulse (8.0 vs. 24.7; p=0.000), time to heel rise (32.1% of stance phase vs. 61.9%; p=0.000), and decreased pressure of the medial forefoot segment (40.8 vs. 52.2; p=0.009). The children were divided into two groups depending on the ankle power generated on the hemiplegic side (<8.0 watts/kg and =/>8.0 watts/kg). Those with an ankle power generation of =/>8.0 watts/kg had significantly longer step length (49 cm vs. 41 cm; p=0.001) and increased velocity (109 cm/sec vs. 89 cm/sec; p=0.000) in gait analysis, and in pedobarographic measurements, increased heel impulse (11.6 vs. 4.4; p=0.047), time to heel rise (46.6% vs. 17.1%; p=0.000), and less varus/valgus positioning (11.1 degrees vs. -34.6 degrees ; p=0.013). In bivariate correlation analysis, ankle power generation on the hemiplegic side demonstrated a significant association with time to heel rise (r=0.574; p=0.000) and varus/valgus positioning (r=0.420; p=0.017), and almost a significant association with heel pressure (r=0.342; p=0.052). CONCLUSION Deviations in the pedobarographic data are reflected in the power generation of the ankle joint and can be of help in decision making of treatment in spastic hemiplegic CP. We speculate that efforts to normalize the heel segment pattern may result in decreased power generation differences.

Muscle fatigue after Achilles tendon rupture: A limited heel-rise test with electromyography reveals decreased endurance

Abstract Measuring the maximal number of heel-rises is the clinical standard to quantify plantarflexor strength. However, this activity can be difficult and uncomfortable after Achilles tendon rupture (ATR) and may capture aspects other than muscle strength and endurance. Therefore, the aim of this study project was to evaluate muscle fatigue with a limited number of heel-rises. Fifty-two patients with ATR were evaluated 2.0-6.7 years after injury. Patients performed the heel-rise test with surface electromyography (sEMG) of the gastrocnemius muscles. Muscle fatigue was operationally defined as the slope of the sEMG signal frequency. Subjects performed significantly fewer heel-rises on the injured side compared with the uninjured side (25.5 ± 9.3 vs 33.6 ± 15.1; p < 0.001). Subjects also had greater muscle fatigue on the injured side compared with the uninjured side for the lateral gastrocnemius (−31.1 ± 13.9 vs -26.2 ± 14.8; p = 0.048), but not the medial gastrocnemius (p = 0.074). There was a significant increase in fatigue of both the lateral and medial gastrocnemius on the injured side over the first 10 repetitions (p < 0.001). Our findings demonstrate that subjects have increased gastrocnemius muscle fatigue even several years after ATR and muscle fatigue can be detected with a limited number of heel-rises.