John Henley

Wilmington robotic exoskeleton: a novel device to maintain arm improvement in muscular disease.

Background Upper-extremity movement is limited in individuals with muscular weakness. This paper describes a novel, articulated upper-extremity orthosis, the Wilmington Robotic Exoskeleton (WREX), which helps people overcome this movement deficit. Methods This prospective, case-controlled study involved an ambulatory patient with arthrogryposis multiplex congenita and 2 nonambulatory patients with spinal muscular atrophy type II. The WREX uses elastic bands to negate the effects of gravity; it allows a person with neuromuscular weakness to move their arm in 3 dimensions. The WREX can be fixed on a brace for ambulatory patients and on the wheelchair for nonambulatory patients. Assessment was performed through motion analysis (with and without the WREX), clinical examination, and qualitative questionnaire. Results Motion analysis showed a marked improvement in upper-extremity function with the WREX. The questionnaire illustrated enhanced functionality with the WREX including self-feeding, fine motor control, and use of a television remote control. Enhanced functionality resulted in improved quality of life by increasing participation in school, raising self-esteem, and increasing social interaction. Two unexpected outcomes were increased security with trunk inclination and amelioration of the effects of contractures. Conclusions The WREX provided an increase in functionality and improved the quality of life of the patients. The device has become an integral part of the lives of the 3 patients. Level of Evidence Level III in Therapeutic Studies-Investigating the Results of Treatment.

A comprehensive outcome comparison of surgical and Ponseti clubfoot treatments with reference to pediatric norms

PurposeIsolated congenital clubfoot can be treated either operatively (posteromedial release) or conservatively (Ponseti method). This study retrospectively compared mid-term outcomes after surgical and Ponseti treatments to a normal sample and used multiple evaluation techniques, such as detailed gait analysis and foot kinematics.MethodsTwenty-six children with clubfoot treated surgically and 22 children with clubfoot treated with the Ponseti technique were evaluated retrospectively and compared to 34 children with normal feet. Comprehensive evaluation included a full gait analysis with multi-segment and single-segment foot kinematics, pedobarograph, physical examination, validated outcome questionnaires, and radiographic measurements.ResultsThe Ponseti group had significantly better plantarflexion and dorsiflexion range of motion during gait and had greater push-off power. Residual varus was present in both treatment groups, but more so in the operative group. Gait analysis also showed that the operative group had residual in-toeing, which appeared well corrected in the Ponseti group. Pedobarograph results showed that the operative group had significantly increased varus and significantly decreased medial foot pressure. The physical examination demonstrated significantly greater stiffness in the operative group in dorsiflexion, plantarflexion, ankle inversion, and midfoot abduction and adduction. Surveys showed that the Ponseti group had significantly more normal pediatric outcome data collection instrument results, disease-specific indices, and Dimeglio scores. The radiographic results suggested greater equinus and cavus and increased foot internal rotation profile in the operative group compared with the Ponseti group.ConclusionsPonseti treatment provides superior outcome to posteromedial release surgery, but residual deformity still persists.

Comprehensive vestibular and balance testing in the dizzy pediatric population

Objective. To describe the spectrum of balance disease in a large population of children presenting to a tertiary care vestibular and balance laboratory. Study Design. Case series with chart review. Setting. Tertiary care pediatric hospital. Main Outcome Measures. Results of audiometric, vestibular, and balance tests and final diagnosis. Subjects and Methods. Retrospective review of audiometric, vestibular, balance testing, and final diagnosis from a patient database. Results. Between September 2003 and September 2007, 132 children were evaluated at the Alfred I. duPont Hospital for Children Vestibular Disorders Program. Sixty-nine of the patients were boys and 63 were girls. The average age was 9.7 ± 5.0 years (range, 1-17 years). Although not all were able to complete the entire test battery (99 children completed at least 50% of the tests in the protocol), a diagnosis was achieved in most cases. The most common diagnoses were peripheral vestibulopathy (29.5%), migraine/benign recurrent vertigo of childhood (24.2%), motor/developmental delay (10.6%), traumatic brain injury (9.8%), and central nervous system structural lesion (9.1%). Conclusions. Peripheral vestibular deficits and migraine disease account for most of the pathology in the pediatric population. With a multidisciplinary approach, diagnosis of the source of vertigo and imbalance is possible in most children.

Gait pattern and lower extremity alignment in children with Morquio syndrome.

The gait in children with Morquio syndrome (MPS IV) has not been previously described. We reviewed the charts, gait analysis reports, and radiographs of nine children with no previous lower extremity surgery. Children with MPS IV had a slower walking speed, reduced cadence, and reduced stride length as compared with normal (P<0.05). There was increased knee flexion, genu valgus, and external tibial torsion during stance (P<0.05). Kinetics showed that knee varus moment was increased (P<0.05). There was a strong correlation between genu valgus measured on gait analysis and standing radiographs (r=0.89).

Persistence and Recurrence Following Femoral Derotational Osteotomy in Ambulatory Children With Cerebral Palsy

Background: Excessive hip internal rotation is frequently seen in children with cerebral palsy (CP). Femoral derotational osteotomy (FDO) is effective in the short term, but factors associated with long-term correction remain unclear. The purposes of this study were to define the incidence of persistence and recurrence of hip internal rotation following FDO in ambulatory children with CP and to evaluate factors that influence outcome. Methods: Following IRB approval, kinematic and passive range of motion (PROM) variables were retrospectively evaluated in children with spastic CP who had FDO to correct hip internal rotation as part of clinical care at a children’s specialty hospital. Children included had a preoperative evaluation (Vpre), a short-term postoperative evaluation (Vshort, 1 to 3 y post), and, in some cases, a long-term postoperative evaluation (Vlong, ≥5 y post). Age at surgery, physical exam measures, and kinematics variables were evaluated as predictors for dynamic and static recurrence. Results: Kinematic hip rotation improved from 14±12 degrees (Vpre; internal positive) to 4±13 degrees (Vshort) and relapsed to 9±15 degrees long term (P<0.05 Vpre/Vshort/Vlong; 99 limbs). Hip PROM midpoint improved from 23±9 degrees (Vpre) to 8±11 degrees (Vshort) and relapsed to 14±13 degrees (P<0.01 Vpre/Vshort/Vlong). Persistent hip internal rotation was noted in 41% (kinematics) and 18% (PROM) of limbs at Vshort (105 children, 178 limbs). Of limbs that showed initial improvement at Vshort (62 children, 95 limbs), recurrence was seen in 40% (kinematic hip rotation) and 39% (hip midpoint) at Vlong. Comparing children who had recurrent hip internal rotation and those who maintained long-term correction, we saw higher levels of spasticity and lower gait velocity in the recurrent group (P<0.05). Conclusions: Although FDO is an accepted treatment in children with CP, persistence and recurrence of hip internal rotation can occur. Recurrence is associated with spasticity and slower gait velocity. Predictor variables may be useful for surgeons during preoperative discussions of expected outcome with families of FDO candidates. Level of Evidence: Level III.

Reliability and validity of Edinburgh visual gait score as an evaluation tool for children with cerebral palsy

Assessment of gait abnormalities in cerebral palsy (CP) is challenging, and access to instrumented gait analysis is not always feasible. Therefore, many observational gait analysis scales have been devised. This study aimed to evaluate the interobserver reliability, intraobserver reliability, and validity of Edinburgh visual gait score (EVGS). Video of 30 children with spastic CP were reviewed by 7 raters (10 children each in GMFCS levels I, II, and III, age 6-12 years). Three observers had high level of experience in gait analysis (10+ years), two had medium level (2-5 years) and two had no previous experience (orthopedic fellows). Interobserver reliability was evaluated using percentage of complete agreement and kappa values. Criterion validity was evaluated by comparing EVGS scores with 3DGA data taken from the same video visit. Interobserver agreement was 60-90% and Kappa values were 0.18-0.85 for the 17 items in EVGS. Reliability was higher for distal segments (foot/ankle/knee 63-90%; trunk/pelvis/hip 60-76%), with greater experience (high 66-91%, medium 62-90%, no-experience 41-87%), with more EVGS practice (1st 10 videos 52-88%, last 10 videos 64-97%) and when used with higher functioning children (GMFCS I 65-96%, II 58-90%, III 35-65%). Intraobserver agreement was 64-92%. Agreement between EVGS and 3DGA was 52-73%. We believe that having EVGS as part of the standardized gait evaluation is helpful in optimizing the visual scoring. EVGS can be a supportive tool that adds quantitative data instead of only qualitative assessment to a video only gait evaluation.

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.

Kinematic and kinetic analysis of planned and unplanned gait termination in children

Gait termination is a task which requires people to alter momentum and stabilize the body. To date, many of the kinematic and kinetic characteristics of gait termination have not been reported, making it difficult for clinicians to design interventions to improve the ability to terminate gait quickly and efficiently. Therefore, the purpose of this study was to describe the lower body mechanics of healthy children as they performed walking trials, planned stopping trials, and unplanned stopping trials. Kinematic and kinetic data were collected from 15 healthy children between the ages of 11 and 17 years (14.3±2.1 years). The timing and magnitude of peak sagittal plane joint angles and moments were compared across the three conditions for the leg that led the stop step. Most differences were found when comparing unplanned stopping to both walking and planned stopping. During unplanned stopping, most subjects used either a hip/knee extension strategy or hip/knee flexion strategy to stabilize and perform the stopping task. The magnitudes of the peak hip extension moment and peak knee flexion angle were significantly greater, while the peak plantarflexion moment was significantly smaller during unplanned stopping than walking and planned stopping. The peak plantarflexion moment occurred significantly earlier during the stop stance phase of planned and unplanned stopping than during walking. This suggests that the ability to create sufficient joint moments in a short period of time is essential to be able to stop quickly and safely. Therefore, possible treatments/interventions should focus on ensuring that patients have appropriate strength, power, and range of motion.

The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy.

Crouched gait is common in children with cerebral palsy (CP), and there are various treatment options. This study evaluated the effectiveness of single-event multilevel surgery including posterior knee capsulotomy or distal femoral extension osteotomy to correct knee flexion contracture in children with CP. Gait analyses were carried out to evaluate gait preoperatively and postoperatively. Significant improvements were found in physical examination and kinematic measures, which showed that children with CP and crouched gait who develop knee flexion contractures can be treated effectively using single-event multilevel surgery including a posterior knee capsulotomy or distal femoral extension osteotomy.

Long-term Outcome of Internal Tibial Derotation Osteotomies in Children With Cerebral Palsy.

Background: External tibial torsion (ETT) is a common bony deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome following TDO to correct ETT in ambulatory children with CP. Methods: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ETT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, E0 MTR, E0 gait velocity, gross motor function classification system (GMFCS) score, and foot deformity were evaluated to determine their influence on long-term results. Results: The study sample consisted of 43 legs (with E0 and E2) and 22 legs (with E0, E1, and E2). The mean age at surgery was 10.3±3.4 years (range, 6 to 19.2 y). In the group MTR trended toward improvement moving from −26±17 degrees (E0, external negative) to −16±16 degrees (E1) and relapsed to −23±17 degrees at the long term (P=0.071, E0/E1; P=0.589, E0/E2). Improvement was also seen in the transmalleolar axis (P=0.074), mean ankle rotation, and mean foot orientation (P<0.05, E0/E2). At the long-term evaluation, 16 legs (37%) were found to be in the kinematic corrected group, 25 legs (58%) in the kinematic undercorrected group, and 2 legs (5%) in the kinematic overcorrected group. There were no significant differences between the corrected and undercorrected groups of children with respect to age at surgery, GMFCS, E0 MTR, gait velocity, or foot deformity. Conclusions: Although internal TDO improves ETT in the short term, recurrence is frequent with an apparent developmental trend toward external rotation of the tibia. Levels of Evidence: Level IV—therapeutic study.