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Abnormalities in the uninvolved leg in children with spastic hemiplegia. The effect of actual and functional leg length discrepancy
54
Abstracts
Joint angles, moments and powers in the sagittal, coronal and transverse planes were calculated over nee gait cycle (VCM) Maxiranm and n'~fimum values were ide~ltifiedand work was calculated. The total bedy courter of mass (COM) was calculated segmeraally in three planes and ks displacement trajectory over the gait cycle was plotted. Results & Discussion Compensato~ strategies identified during gait were pea~stent hip and knee flexion of the long limb in swing phase, vanlling over the short limb, drcumduction of the long limb in swing phase and toe walking on the short limb during stance phase. Per,~tent flexion was objectivdy defined as hip or knee flexion of greater than 5° throughout the gait cycle. Vaulting over the short limb appeared as early hod rise prior to long limb swing phase. Ciroarnduction was identified as greater than one standard deviation of normal hip abduction or hip external rotation in swing phase. Toe walking was identified as a plantarflexion angle at initial coraact.
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The knee was flexed throughout the gait cycle but particularly in stance, where ground contact was in excessive flexion and the loading response was exaggerated. The pattern of ankle movement was particularly abnormal. T here was an increased range of dorsiflexion during both stance and swing with a reduction of the normal plantarflexion at toe-off. In the hemiplegic limb, the range of movement at the hip and knee was reduced, with all movement occurring in flexion. The majority of the childran with hemiplegia had a foot drop. In the children with hemiplegia without a leg length discrepancy, the pattern was essentially similar to those with a leg length discrepancy, although the changes in the uninvolved leg were less marked. Discussion: All children with spastic hemiplegia in our study demonstrated typical sagittal plane abnormalities in the involved leg which have been previously described. 3 In this study, we have identified that there are characteristic abnormalities in the uninvolved leg that have not been previousIy described. These include excessive dorsiflexion of the ankle in stance and increased hip and knee flexion throughout the gait cycle. We believe that these changes are the result of eompensatiun in a functionally, if not actually, longer but normal leg. The changes have the effect of shortening the uninvolved limb, making walking at the level of the pelvis more symmelrical. These findings have important clinical implications. We recommend that close attention be paid to the functional leg length discrepancy in children with hemiplegic cerebral palsy and early consideration be given to limb equalisation.
References: Figure 1: EighteenLLDpatieraswithmeasuredLLD(%)atfimeofbothtest~ Black indieates the presence ofany idemified gait deviation. White indicates normal plantigrade gait. All eighteen patients exhibited at least one of the four gait deviations at the time of initial testing. Ten patients initially walked with persistent hip or knee flexion. Only one patient who was corrected to below 3% continued to exhibit persistent flexion at followup. Vaulting was seen in five patients and circumduetion was seen in eight patients initially. All patients, regardless of the amount correction, stopped vaulting at follow-up. Two patients corrected below 3% continued to eiroumduet. Twelve patients, with an LLD between 3.0% and 21.9%, were toe walkers at the time o f initial testing. Two patients who had correction to below 3% continued to walk on their toes at follow-up. Surgical correction to within 5.5% of the length of the long limb was achieved in fifteen and to within 3% in eight patients. The total limb work in these ftt~en patients did not differ from normal at follow-up. The mediolateral and vertical displacement o f the COM also fell within ~:1 SD of normal. The gait of LLD patient's tends toward normal as their leg length equalizes. Although correction to 3% may alleviate almost all gait deviations, correction to 5.5% alleviates enough to improve gait efficiency. Referene~ Kaufinan, K.IL IVfaller,L.S. Suthedand, D.I-I. J. Pedlar. Orthop. 16:144-150, 1996. Song, K.M. Halliday, S.E. Little, D.G. JBJS. 79(a):1690-1698,1997.
ABNORMALITIES IN THE UNINVOLVED LEG IN CHILDREN W I T H SPASTIC HEMIPLEGIA. THE EFFECT OF ACTUAL AND FUNCTIONAL LEG LENGTH DISCREPANCY. PE Allen, FRCS(Orth), A Jeakinson, MISCP, MM Stephens, MSc, FRCSI, T O'Brien, MCh, FRCSI. The Gait Laboratory, Central Remedial Clinic, Clantarf, Dublin. Introduction. Gait analysis has become an important tool in the assessment of children with cerebral palsy. Children with spastic hemiplegia have the potential to develop a leg length discrepancy. Although several papers describe the changes in gait following various surgical procedures, little has been written about the pattern of gait in children with spastic hemiplegia, and there have been no descriptions of either the kinematics of the uninvolved limb, or the effect of a leg len~h discrepancy on gait. 1,2 the aim of this study was to assess the kinematics of the uninvolved lower limbs and compare them with the involved limbs of children with spastic hemiplegia. We also looked at the effect of leg length discrepancy on gait in these patients and compared the kinematics of the lower limbs with data obtained from normal children. Methodology: One hundred and forty eight children with spastic hemiplegia and 61 normal children underwent gait analysis. All had a full clinical examination, including leg length measurement and kinematie assessment with the CODA-3 motion analyser. Twenty different gait parameters from each leg were compared between the three groups (ie the uninvolved lower limb in hemiplegic children, the involved lower limb in these children and normal limbs in normal children). Results: forty nine children with hemiplegia had a measured leg length discrepancy of 1.5cm or more. None of the normal children had a measured discrepancy of greater than 0.5cm. No child had undergone previous surgery. The children with spastic hemiplegia had a reduced velocity of walking compared to that in normal children. The pattern of gait in the uninvolved limb of children with spastic hemiplegia and a leg length discrepancy was characteristic. Hip movement was increased and occurred in flexion.
l. 2. 3.
Gage JR, Fabian D, Hicks R, Tashman S. Pre- and postoperative gait analysis in patients with spastic diplegia: a preliminary report. JPaediatr Orthop 1984;4:715-25 Winters TF, Gage JR, Hicks R. Gait patterns in spastic hemiplegia in children and young adults. JBone Joint Surg 1987; 69-A: 437-41 O'Byrne JM, Jenkinson A, O'Brien T. Quantitative analysis and classification of gait patterns in cerebral palsy using a three-dimensional motion analyser, d Child Neur 1998; 13:1-8
L O C A T I O N O F S H O U L D E R R O T A T I O N AXES D U R I N G E L E V A T I O N Caroline Doorenbosch ~, Anneke Mourits 2, DirkJan Veeger:, Jaap Harlaar ~, Frans van der Helm 3 hDept. Rehab.Med, University Hospital VU, Amsterdam, The Netherlands 2Faculty of Human Movement Sciences, VU Amsterdam, The Netherlands J Dept. Mech. Eng. Delft University of Technology, Delft, The Netherlands INTRODUCTION In function assessment o f the upper extremity, the shoulder is usually regarded as a ball joint. For a valid measurement of the net joint moment with dynamometry, the instrumental axis of rotation should be aligned with the assumed anatomical center of rotation of the shoulder. However, many studies do not describe the exact position of the joint axis (e.g. 2, 3) and some papers indicated the center of rotation at the humeral head in all cases (e.g. 5, 6, 7). I f the humeral head was the only bone that rotates in order to move the arm from the trunk, this assumption would be acceptable. However, since also the movement o f the scapula plays an important role in the range of motion of the shoulder mechanism, the assumption of a shoulder rotation axis at the humeral head is a p d o d not likely. In this study it will be investigated whether a single shoulder axis of rntation daring elevation can be identified and to outline its location. METHODOLOGY Healthy subjects (n=7; height 1.79_+0.08m) with no known history o f shodider problems, participated in the experiments. They were seated on a chair with their trunk fixed and were instructed to elevate their right arm slowly in the coronal or sagittal plane. Landmark positions, placed on the elbow, shoulder, the sixth cervical vertebra and on the seat o f the subject, were collected with V I C O N motion analysis system (60Hz). Off-line analysis started with a circle fit procedure of the coordinates of the elbow marker for each completed range of motion (CROM) in each plane. The mean location of the fitted center with respect to the acromion marker was considered to be the location o f the shoulder rotation axis for that subject in that specific plane of elevation. Finally, mean values of these relative locations for all subjects were averaged to obtain a 'single' projection of the shoulder rotation axis in each plane. RESULTS Several trajectories of the path of the elbow marker are shown for one subject in Figure 1. The elbow marker clearly describes a path that is part of a circle for both planes o f elevation. The circle fits were very accurate in both planes (RMSE < 2%). Table l shows the overall averaged distance o f the rotation point in both planes. In the sagittal plane, the location of rotation axis is 0.8 cm. dorsal and 2.2 cm caudal from aeromion marker. For the elevation movement in the coronal plane, the averaged position o f the estimated rotation axis was found at 13.3 cm medial and about 1.7 cm caudal relative to the midpoint of the lateral acromion side (see also Figure 1). elevation in sagittal plane I elevation in coronal plane X [ Z [ Y Z -0.8_+0.6(cm) [ -2.2_+0.4(cm) [ 13.3_+0.8(cm) -1.7±0.4(cm Table 1. Mean distances in centimeters (_+SD)of the rotation axis relative to the starting position of the acromion, derived from all #CROM and all subjects (n=7).
Abstracts
Joint angles, moments and powers in the sagittal, coronal and transverse planes were calculated over nee gait cycle (VCM) Maxiranm and n'~fimum values were ide~ltifiedand work was calculated. The total bedy courter of mass (COM) was calculated segmeraally in three planes and ks displacement trajectory over the gait cycle was plotted. Results & Discussion Compensato~ strategies identified during gait were pea~stent hip and knee flexion of the long limb in swing phase, vanlling over the short limb, drcumduction of the long limb in swing phase and toe walking on the short limb during stance phase. Per,~tent flexion was objectivdy defined as hip or knee flexion of greater than 5° throughout the gait cycle. Vaulting over the short limb appeared as early hod rise prior to long limb swing phase. Ciroarnduction was identified as greater than one standard deviation of normal hip abduction or hip external rotation in swing phase. Toe walking was identified as a plantarflexion angle at initial coraact.
:2
21 18 1 15
_t -
-
o
The knee was flexed throughout the gait cycle but particularly in stance, where ground contact was in excessive flexion and the loading response was exaggerated. The pattern of ankle movement was particularly abnormal. T here was an increased range of dorsiflexion during both stance and swing with a reduction of the normal plantarflexion at toe-off. In the hemiplegic limb, the range of movement at the hip and knee was reduced, with all movement occurring in flexion. The majority of the childran with hemiplegia had a foot drop. In the children with hemiplegia without a leg length discrepancy, the pattern was essentially similar to those with a leg length discrepancy, although the changes in the uninvolved leg were less marked. Discussion: All children with spastic hemiplegia in our study demonstrated typical sagittal plane abnormalities in the involved leg which have been previously described. 3 In this study, we have identified that there are characteristic abnormalities in the uninvolved leg that have not been previousIy described. These include excessive dorsiflexion of the ankle in stance and increased hip and knee flexion throughout the gait cycle. We believe that these changes are the result of eompensatiun in a functionally, if not actually, longer but normal leg. The changes have the effect of shortening the uninvolved limb, making walking at the level of the pelvis more symmelrical. These findings have important clinical implications. We recommend that close attention be paid to the functional leg length discrepancy in children with hemiplegic cerebral palsy and early consideration be given to limb equalisation.
References: Figure 1: EighteenLLDpatieraswithmeasuredLLD(%)atfimeofbothtest~ Black indieates the presence ofany idemified gait deviation. White indicates normal plantigrade gait. All eighteen patients exhibited at least one of the four gait deviations at the time of initial testing. Ten patients initially walked with persistent hip or knee flexion. Only one patient who was corrected to below 3% continued to exhibit persistent flexion at followup. Vaulting was seen in five patients and circumduetion was seen in eight patients initially. All patients, regardless of the amount correction, stopped vaulting at follow-up. Two patients corrected below 3% continued to eiroumduet. Twelve patients, with an LLD between 3.0% and 21.9%, were toe walkers at the time o f initial testing. Two patients who had correction to below 3% continued to walk on their toes at follow-up. Surgical correction to within 5.5% of the length of the long limb was achieved in fifteen and to within 3% in eight patients. The total limb work in these ftt~en patients did not differ from normal at follow-up. The mediolateral and vertical displacement o f the COM also fell within ~:1 SD of normal. The gait of LLD patient's tends toward normal as their leg length equalizes. Although correction to 3% may alleviate almost all gait deviations, correction to 5.5% alleviates enough to improve gait efficiency. Referene~ Kaufinan, K.IL IVfaller,L.S. Suthedand, D.I-I. J. Pedlar. Orthop. 16:144-150, 1996. Song, K.M. Halliday, S.E. Little, D.G. JBJS. 79(a):1690-1698,1997.
ABNORMALITIES IN THE UNINVOLVED LEG IN CHILDREN W I T H SPASTIC HEMIPLEGIA. THE EFFECT OF ACTUAL AND FUNCTIONAL LEG LENGTH DISCREPANCY. PE Allen, FRCS(Orth), A Jeakinson, MISCP, MM Stephens, MSc, FRCSI, T O'Brien, MCh, FRCSI. The Gait Laboratory, Central Remedial Clinic, Clantarf, Dublin. Introduction. Gait analysis has become an important tool in the assessment of children with cerebral palsy. Children with spastic hemiplegia have the potential to develop a leg length discrepancy. Although several papers describe the changes in gait following various surgical procedures, little has been written about the pattern of gait in children with spastic hemiplegia, and there have been no descriptions of either the kinematics of the uninvolved limb, or the effect of a leg len~h discrepancy on gait. 1,2 the aim of this study was to assess the kinematics of the uninvolved lower limbs and compare them with the involved limbs of children with spastic hemiplegia. We also looked at the effect of leg length discrepancy on gait in these patients and compared the kinematics of the lower limbs with data obtained from normal children. Methodology: One hundred and forty eight children with spastic hemiplegia and 61 normal children underwent gait analysis. All had a full clinical examination, including leg length measurement and kinematie assessment with the CODA-3 motion analyser. Twenty different gait parameters from each leg were compared between the three groups (ie the uninvolved lower limb in hemiplegic children, the involved lower limb in these children and normal limbs in normal children). Results: forty nine children with hemiplegia had a measured leg length discrepancy of 1.5cm or more. None of the normal children had a measured discrepancy of greater than 0.5cm. No child had undergone previous surgery. The children with spastic hemiplegia had a reduced velocity of walking compared to that in normal children. The pattern of gait in the uninvolved limb of children with spastic hemiplegia and a leg length discrepancy was characteristic. Hip movement was increased and occurred in flexion.
l. 2. 3.
Gage JR, Fabian D, Hicks R, Tashman S. Pre- and postoperative gait analysis in patients with spastic diplegia: a preliminary report. JPaediatr Orthop 1984;4:715-25 Winters TF, Gage JR, Hicks R. Gait patterns in spastic hemiplegia in children and young adults. JBone Joint Surg 1987; 69-A: 437-41 O'Byrne JM, Jenkinson A, O'Brien T. Quantitative analysis and classification of gait patterns in cerebral palsy using a three-dimensional motion analyser, d Child Neur 1998; 13:1-8
L O C A T I O N O F S H O U L D E R R O T A T I O N AXES D U R I N G E L E V A T I O N Caroline Doorenbosch ~, Anneke Mourits 2, DirkJan Veeger:, Jaap Harlaar ~, Frans van der Helm 3 hDept. Rehab.Med, University Hospital VU, Amsterdam, The Netherlands 2Faculty of Human Movement Sciences, VU Amsterdam, The Netherlands J Dept. Mech. Eng. Delft University of Technology, Delft, The Netherlands INTRODUCTION In function assessment o f the upper extremity, the shoulder is usually regarded as a ball joint. For a valid measurement of the net joint moment with dynamometry, the instrumental axis of rotation should be aligned with the assumed anatomical center of rotation of the shoulder. However, many studies do not describe the exact position of the joint axis (e.g. 2, 3) and some papers indicated the center of rotation at the humeral head in all cases (e.g. 5, 6, 7). I f the humeral head was the only bone that rotates in order to move the arm from the trunk, this assumption would be acceptable. However, since also the movement o f the scapula plays an important role in the range of motion of the shoulder mechanism, the assumption of a shoulder rotation axis at the humeral head is a p d o d not likely. In this study it will be investigated whether a single shoulder axis of rntation daring elevation can be identified and to outline its location. METHODOLOGY Healthy subjects (n=7; height 1.79_+0.08m) with no known history o f shodider problems, participated in the experiments. They were seated on a chair with their trunk fixed and were instructed to elevate their right arm slowly in the coronal or sagittal plane. Landmark positions, placed on the elbow, shoulder, the sixth cervical vertebra and on the seat o f the subject, were collected with V I C O N motion analysis system (60Hz). Off-line analysis started with a circle fit procedure of the coordinates of the elbow marker for each completed range of motion (CROM) in each plane. The mean location of the fitted center with respect to the acromion marker was considered to be the location o f the shoulder rotation axis for that subject in that specific plane of elevation. Finally, mean values of these relative locations for all subjects were averaged to obtain a 'single' projection of the shoulder rotation axis in each plane. RESULTS Several trajectories of the path of the elbow marker are shown for one subject in Figure 1. The elbow marker clearly describes a path that is part of a circle for both planes o f elevation. The circle fits were very accurate in both planes (RMSE < 2%). Table l shows the overall averaged distance o f the rotation point in both planes. In the sagittal plane, the location of rotation axis is 0.8 cm. dorsal and 2.2 cm caudal from aeromion marker. For the elevation movement in the coronal plane, the averaged position o f the estimated rotation axis was found at 13.3 cm medial and about 1.7 cm caudal relative to the midpoint of the lateral acromion side (see also Figure 1). elevation in sagittal plane I elevation in coronal plane X [ Z [ Y Z -0.8_+0.6(cm) [ -2.2_+0.4(cm) [ 13.3_+0.8(cm) -1.7±0.4(cm Table 1. Mean distances in centimeters (_+SD)of the rotation axis relative to the starting position of the acromion, derived from all #CROM and all subjects (n=7).