Sylvia Õunpuu

Natural progression of gait in children with cerebral palsy.

Twenty-eight children with cerebral palsy had two gait analyses an average of 4.4 years apart with no surgical intervention between the tests. The effects of growth and age were examined using three-dimensional kinematics, temporal and stride parameters, and clinical examination measures. Kinematic changes showed decreases in hip, knee, and ankle sagittal plane ranges of motion (ROM), peak hip flexion in swing, and peak knee flexion over time. Temporal and stride parameters showed declines in timing of toe off, cadence, and walking velocity. Clinical measures showed declines in hip abduction ROM (knees flexed and extended), popliteal angle, and sagittal plane ankle ROM (knees flexed and extended). Overall results showed that gait function in these individuals with cerebral palsy decreased longitudinally with respect to temporal/stride measures, passive ROM, and kinematic parameters compared with a group of individuals who had had orthopaedic intervention.

Three-dimensional lower extremity joint kinetics in normal pediatric gait

Gait analysis is becoming a more integral part of the decision-making process in treatment of children with neuromuscular problems. A normal reference, however, must be available for comparison when one makes decisions. We wished to develop a normal pediatric database for joint kinematics and kinetics which could then be used as a reference for clinical gait analysis. Thirty-one normal children underwent a complete gait analysis including calculations of three-dimensional joint kinematics and kinetics. The pediatric data were similar to that of normal adults.

Alterations in surgical decision making in patients with cerebral palsy based on three-dimensional gait analysis.

The purpose of this study was to compare surgical recommendations made by clinicians experienced in gait analysis when using information provided from the clinical examination and videotape, with recommendations made after the addition of kinematic, kinetic, and electromyographic (EMG) data. Ninety-one patients with a diagnosis of cerebral palsy were seen in the gait laboratory as part of the surgical decision-making process. Experienced clinicians reviewed video and clinical examination data for each patient and made surgical recommendations. Joint kinematics and kinetics and EMG data were then reviewed, and a second set of surgical recommendations was made. Comparisons between these recommendations showed that the addition of gait-analysis data resulted in changes in surgical recommendations in 52% of the patients, with an associated reduction in cost of surgery, not to mention the human impact of an inappropriate surgical decision, which is more likely without gait analysis. When changes in recommendations were made, an increase in surgical recommendations was observed for the gastrocnemius (59%) and rectus femoris (65%), whereas decreases were observed for the hamstrings (61%), psoas (78%), hip adductors (83%), femur (86%), and tibia (64%).

Kinematic and kinetic evaluation of the ankle after lengthening of the gastrocnemius fascia in children with cerebral palsy.

Summary: The effect of surgical lengthening of the gastrocnemius fascia on ankle joint kinematics and kinetics during gait in patients with cerebral palsy (CP) was evaluated. Twenty independent ambulators (24 sides) were included in this retrospective study. The evaluation included clinical examination, calculation of joint kinematics and kinetics, and collection of surface electromyography (EMG) during gait. Postoperative improvements were noted in static heelcord range of motion (ROM), with an associated increase in dorsiflexion in stance and swing. Kinetic analysis showed a decrease in the abnormal energy generated around the ankle in midstance and a statistically significant increase in the energy generated in late stance for push-off.

Rectus femoris surgery in children with cerebral palsy. Part I: The effect of rectus femoris transfer location on knee motion.

Summary Rectus femoris transfer was performed in 78 children (105 sides) with cerebral palsy (CP) at the same time as other surgical procedures as appropriate. The transfer was either medial to the sartorius (62 sides), semitendinosus (19 sides), or the gracilis (14 sides) muscles, or laterally to the iliotibial band (10 sides). Gait analysis performed before and 1 year after operation demonstrated increased knee range of motion (ROM) with increased extension at initial contact and in midstance and maintained knee flexion in swing. There were no statistically significant differences between the four transfer sites in the effect on those variables. Therefore, the choice of rectus femoris transfer site can be dictated by surgical preference or by the nature of other simultaneous procedures. There was no consistent change in transverse plane motion of the hip or foot progression angles between the two gait analyses, suggesting that rectus femoris transfer does not affect gait abnormalities observed in the transverse plane.

Efficacy of clinical gait analysis: A systematic review

The aim of this systematic review was to evaluate and summarize the current evidence base related to the clinical efficacy of gait analysis. A literature review was conducted to identify references related to human gait analysis published between January 2000 and September 2009 plus relevant older references. The references were assessed independently by four reviewers using a hierarchical model of efficacy adapted for gait analysis, and final scores were agreed upon by at least three of the four reviewers. 1528 references were identified relating to human instrumented gait analysis. Of these, 116 original articles addressed technical accuracy efficacy, 89 addressed diagnostic accuracy efficacy, 11 addressed diagnostic thinking and treatment efficacy, seven addressed patient outcomes efficacy, and one addressed societal efficacy, with some of the articles addressing multiple levels of efficacy. This body of literature provides strong evidence for the technical, diagnostic accuracy, diagnostic thinking and treatment efficacy of gait analysis. The existing evidence also indicates efficacy at the higher levels of patient outcomes and societal cost-effectiveness, but this evidence is more sparse and does not include any randomized controlled trials. Thus, the current evidence supports the clinical efficacy of gait analysis, particularly at the lower levels of efficacy, but additional research is needed to strengthen the evidence base at the higher levels of efficacy.

Long-term effects of femoral derotation osteotomies: an evaluation using three-dimensional gait analysis.

The purpose of this study was to evaluate the long-term effects of the femoral derotation osteotomy (FDO) in the ambulatory patient with cerebral palsy (CP). The effectiveness of the FDOs were evaluated using three-dimensional gait analysis just before surgery (P0), 1 year after surgery (P1), and 5 years after surgery (P2). A total of 20 patients (27 sides) with CP were evaluated. Related physical examination and motion measures showed significant improvements at P1 that were maintained at P2. Mean maximum internal hip rotation at P0 of 77° ± 9° decreased to 53° ± 8° at P1 and was maintained at 58° ± 11° at P2. Mean maximum external hip rotation at P0 of 21° ± 11° increased to 35° ± 15° at P1 and was maintained at 32° ± 13° at P2. Mean femoral anteversion at P0 of 63° ± 9° was reduced to 26° ± 15° and was maintained at 31° ± 13° at P2. During gait, mean hip rotation in stance at P0 of 20° ± 8° was decreased to 2° ± 10° at P1 and was maintained at 4° ± 5° at P2. There were associated significant foot progression changes from an internal progression mean of 5° ± 17° at P0 to −11° ± 17° at P1 that were maintained at −12° ± 5° at P2. The findings suggest that the FDO is a viable and lasting treatment option for the correction of anteversion and associated internal hip rotation during gait in children with CP.

Effect of hamstring and psoas lengthening on pelvic tilt in patients with spastic diplegic cerebral palsy.

The purpose of this study was to evaluate the effects of hamstring lengthenings and psoas recessions over the brim of the pelvis (OTB) on pelvic function in the gait of patients with spastic cerebral palsy. Seventy-three patients were divided into four groups based on surgical intervention: medial hamstrings (n = 37), medial and lateral hamstrings (n = 12), medial hamstrings with psoas OTB (n = 9), and medial and lateral hamstrings with psoas OTB (n = 15). Three-dimensional gait analysis was completed both before and approximately 1 year after surgery. When pelvic position in gait was normal or posterior of normal preoperatively, there was a significant increase in pelvic tilt (p < 0.05) when medial and lateral hamstrings were lengthened, irrespective of simultaneous psoas OTB surgery. Medial hamstrings alone, with or without simultaneous psoas OTB, did not result in a significant change in pelvic position, irrespective of preoperative pelvic position. The only surgical combination that caused a reduction in excessive preoperative anterior pelvic tilt was medial and lateral hamstrings with psoas OTB, a 4 degrees change of limited clinical significance. In general, psoas and medial hamstring surgery have minimal effect on the pelvic position during gait. Medial and lateral hamstring lengthening will increase pelvic tilt if preoperative pelvic position is normal or slightly posteriorly tilted. The results of this study suggest that the fundamental determinants of pelvic position during gait postoperatively are the extent of hamstring surgery (medial only vs. both medial and lateral hamstring lengthening) and the preoperative position of the pelvis.

Rectus femoris surgery in children with cerebral palsy. Part II: A comparison between the effect of transfer and release of the distal rectus femoris on knee motion.

Summary Rectus femoris muscle (RF) surgery was performed in 98 children (136 sides) with cerebral palsy (CP). RF transfer was performed in 105 lower limbs, and distal RF release was performed in 31. Eleven (20 sides) similarly affected children had no RF procedure and are included for comparison. Gait analysis was performed just before and ∼1 year after surgery. All children underwent other orthopaedic surgery at the time of the RF procedure. When preoperative knee range of motion (ROM) was >80% of normal, there were no significant changes in knee motion in either the RF transfer or distal release groups. In patients with <80% of normal knee ROM preoperatively, RF transfer was followed by maintained knee flexion in swing; patients who underwent distal RF release or no RF procedure showed a decrease (10° and 6°, respectively) in knee flexion postoperatively. These results suggest that the RF should be transferred and not released when knee ROM is <80%.

A Biomechanical Comparison of the Fastball and Curveball in Adolescent Baseball Pitchers

Background The incidence of shoulder and elbow injuries in adolescent baseball players is rapidly increasing. One leading theory about this increase is that breaking pitches (such as the curveball) place increased moments on the dominant arm and thereby increase the risk of injury. Hypothesis There is no difference in the moments at the shoulder and elbow between fastball and curveball pitches in adolescent baseball pitchers. Study Design Controlled laboratory study. Methods Thirty-three adolescent baseball pitchers with a minimum of 2 years of pitching experience underwent 3-dimensional motion analysis using reflective markers aligned to bony landmarks. After a warm-up, pitchers threw either a fastball or curveball, randomly assigned, from a portable pitching mound until 3 appropriate trials were collected for each pitch technique. Kinematic and kinetic data for the upper extremities, lower extremities, thorax, and pelvis were collected and computed for both pitch types. Statistical analysis included both the paired sample t test and mixed model regression. Results There were lower moments on the shoulder and elbow when throwing a curveball versus when throwing a fastball. As expected, speed for the 2 pitches differed: fastball, 65.8 ± 4.8 mph; and curveball, 57.7 ± 6.2 mph (P <. 001). Maximal glenohumeral internal rotation moment for the fastball was significantly higher than for the curveball (59.8 ± 16.5 N·m vs 53.9 ± 15.5 N·m; P <. 0001). Similarly, the maximum varus elbow moment for the fastball was significantly higher than for the curveball (59.6 ± 16.3 N·m vs 54.1 ± 16.1 N·m; P <. 001). The wrist flexor moment was greater in the fastball, 8.3 ± 3.6 N·m, than in the curveball, 7.8 ± 3.6 N·m (P <. 001), but the wrist ulnar moment was greater in the curveball, 4.9 ± 2.0 N·m, than in the fastball, 3.2 ± 1.5 N·m (P <. 001). Relatively minor motion differences were noted at the shoulder and elbow throughout the pitching motion, while significant differences were seen in forearm and wrist motion. The forearm remained more supinated at each point in the pitching cycle for the curveball but had less overall range of motion (62° ± 20°) than with the fastball (69° ± 17°) (P <. 001), and the difference in the forearm pronation and supination moment between the pitches was not significant (P =. 104 for pronation and P =. 447 for supination). The wrist remained in greater extension during the fastball from foot contact through ball release but did not have significantly different total sagittal range of motion (53° ± 11°) when compared with the curveball (54° ± 15°) (P =. 91). Conclusion In general, the moments on the shoulder and elbow were less when throwing a curveball than when throwing a fastball. In each comparison, the fastball demonstrated higher moments for each individual pitcher for both joints. Clinical Relevance The findings based on the kinematic and kinetic data in this study suggest that the rising incidence of shoulder and elbow injuries in pitchers may not be caused by the curveball mechanics. Further evaluation of adolescent and adult baseball pitchers is warranted to help determine and subsequently reduce the risk of injury.