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Treatment of equinus in young children with hemiplegic cerebral palsy: Recurrance after achilles tendon lengthening and kinematic and kinetic evaluation of treatment with botulnum toxin
90
Abstracts
EFFECTS OF ANKLE FOOT ORTHOSES ON THE GAIT OF CEREBRAL PALSY CHILDREN
K. Desloovere, C. Huenaerts, G. Molenaers, M. Eyssen, P. De Cock. Gait Analysis Laboratory, University Hospital Pellenberg, K. U. Leuven, Belgium
Introduction
Ankle-foot orthoses (AFOs) have been recommended for patients with cerebral palsy (CP) mairdy to correct an equinus gait pattern. A retrospective study was performed on diplegic and hemiplegic patients who had suitable barefoot and AFO gait trials on the same day. The objectives of the present study were to outline the effects of four different types of AF0s (conventional AFOs, fixed AF0s, hinged AFOs and leafsprmgs) on the walking patterns for CP children.
Methodology
Forty-seven children with CP, between the age of 5 and 12 years, participated to the study. The criteria for enrolment into the study were that the children had to be ambulant (no walking aids) with the diagnoses of spastic diplegia or spastic hemiplegla, that the children had been wearing the AFOs for at least two months and that an analysis of gait with and without AFOs was performed on the same day. Fifteen subjects (6 diplegic and 9 hemiplegic) wear conventional orthoses or klenzack (comprising a calfoand, double side steels and a mechanical joint aRaohed to the shoe), ten subjects (6 diplegic and 4 hemiplegic) wear leafsprings, seventeen subjects (11 dipleglc, 6 hemiplegic) wear hinged Polypropylene AFOs, and five subjects (3 diplegic and 2 hemiplegic) wear fixed polypropylene AFOs. A three dimensional gait analysis included kinematics and kinetics using a six camera VICON data capturing system and two AMTI force plates. The data were further processed using the Vicoo Clinical Manager software. Data analysis included comparison of the patients walking barefoot and with AFO, using a two-sample t-test. Variables fi'om kinematic (joint angles) and kinetic (moment and power) results were included in the analysis.
Results Use of an AFO during gait, as compared with the barefoot condition, produced a significant increase in stride length, a more pronounced knee flexion during loadin~ response, and a decrease of the pathological plantar-flexion/knee-exteesion couple. As expected, the ankle was more dorsiflexed at initial contact, and ankle plantar flexion at push offwas restricted. For patients with leafsprings and hinged AFOs, the above changes were accompanied with an increased hip extension at terminal stance and a decrease of hip abduction during swing. All subjects, except for those wearing conventional AFOs, showed a decreased excursion at the pelvis in the transversal plane. Despite of the more pronounced internal alignment of the feet during stance with AFOs as compared to barefoot walking, no effects of the AFO could be noticed on hip rotations. Fixed AFOs caused a more pronounced external knee extension moment during stance (GRF-effect)
were compared before and after botulinum toxin injection. Methodology [study i]: Eleven patients with a mean age of 5.4 (2.5-7.8) years and a follow up of 10.2 (6.8-12.6) years were included. All of them underwent achilles tendon lengthening by a percutanuous sliding technique. Recurrence was defined as a return to equinus leading to repeat lengthening. Results [study i]: Recurrance rate was 45.5%. Mean time between initial and repeat surgery was 5.2 (2.7-12.4) years. Methodology [study 2]: Eight patients with a mean of 4.9 (3.4-7.5) years were included. All of them received botulinum toxin injection in the gastrocnemius muscle. Gait analysis was performed with a mean of 59 (4-129) days before and 61 (42-79) after injection. A paired t test was used to compare the two results. Results [study 2]: Table included. Discussion: In this study with a long follow up the high recurrence rate found is very similar with that in literature. The results of botulinum toxin injection showed significant improvement of ankleflexion at initial contact (p<0.01). Maximum powergeneration during midstance was also reduced significantly (p<0.05). Maxim~impowergeneration during push-off was not changed. Explanation of these results is being discussed in this article. Further study with a longer follow up on treatment with bot~linum toxin and with involvement of the upper joints is necessary, but these results prove a potential for postponing surgery until the age of 7 years with less risk of recurrance. References i. Corry et al. Botulinum toxin A compared with stretching casts in the treatment of spastic equinus: a randomnised prospective trial. J Pediatr Orthop 1998;18:304-11. 2. Cosgrove et al. Botulinum toxin in the management of the lower limb in cerebral palsy. Dev Med Child Neurol 1994;36:386-96. 3. DeLuca. The muscleskeletal management of children with cerebral palsy. Pediatr Clin North Am 1996;43:1135-50. 4. Etnyre et al. Preoperative and postoperative assessment of surgical intervention for equinus gait in children with cerebral palsy. J Pediatr Orthop 1993;13:24-31. 5. Gage. Gait analysis in cerebral palsy. London:Mac Keith Press,1991:102-4,132-50. 6. Komau et al. Management of cerebral palsy with botulinumA toxin: preliminary investigation. J Pediatr Orthop 1993;13:489-95. 7. Olney et al. Work and power in hemiplegic cerebral palsy gait. Phys Thor 1990;70:431-38. 7. Rattey et el. Recurranee after achilles tendon lengthening in cerebral palsy. J Pediatr Orthop 1993;13:18487. 8. Rose et al. Kinematic and kinetic evaluation of the ankle after lengthening of the gastrocnemius fascia in children with cerebral palsy. J Pediatr Orthop 1993;13:727-32. 9. Sharrard et el. Zquinus deformity in cerebral palsy. J Bone Joint Surg;54B:272-76. I0. Yngve et al. Vulpius and Z-lengthening. J Pediatr Orthop 1996;16:759-64. Table Statistical comparison of pre- and postinjection measurements preinjection mean (SD) Velocity
Discussion and conclusion
View the conservative nature of orthotic devices, AFOs are commonly integrated into the management of different aspects associated with CP gait. This study illustrates the beneficial effects of the use of different AFOs on the gait pattern in CP children. Multiple significant effects on the ankle, but also on the proximal joints, were noticed. Comparing four bracing groups, some differences in effects on the gait pattern can be described. The lowest effect on pathological gait seemed to be associated with the use of the conventional AFO.
{m/s)
Steplengtb
(m)
p
1.10
(0.3)
11.08
(0.3)
0.8619
0.42
(0.i)
0.43
(0.1)
0.8411
(6)
-2
(7)
0.0093
I0 (4)
0.1071
Ankleflexion at Initial Contact (degr)
-ii
Maximum dorsiflexion during Stance (degr)
5 (8)
Maximum power generation during Midstanee (Watts/kg)
0.68
(0.6)
0.ii
(0.3)
0.0453
0.96
(0.5)
1.04
(0.6)
0.7960
IMaximum power igeneration during Push-Off (Watts/kg) Treatment of Equinus in Young Children with Hemiplegic Cerebral Palsy: Recurrance after Achilles Tendon Lengthening and Kinematic and Kinetic Evaluation of Treatment with Botulinum Toxin A.W.ZURCHER, G.MOLENAERS, G. FABRY (Pellenberg Hospital, Catholic University Leuven, Belgium) Abstract Introduction: When conservative treatment of equinus in children with cerebral palsy has failed, surgery is indicated performed by either gastrocnemius muscle or achilles tendon lengthening. Both Of these procedures carry a high risk of recurrance, especially in young children with hemiplegic cerebral palsy. In this article was studied the rate of recurrance after achilles tendon lengthening in this particular subgroup. Intramuscular botulinum toxin injection is a promising treatment which can postpone surgery. In a second study in this article kinematic and kinetic results
postinjection mean (SD)
THE LESION OF THE INTERVERTEBRAL DISCS IN MR IMAGE AND THE MOBILITY OF THE LUMBAR SECTION OF THE VERTEBRAL COLUMN MEASURED W I T H A PENNY & GILES ELECTROGONIOMETER.
P. Szulc, P.Bankowial% J.Lewandowski Department of Functional Anatomy, University School of Physical Education, Poznaft, Poland
Abstracts
EFFECTS OF ANKLE FOOT ORTHOSES ON THE GAIT OF CEREBRAL PALSY CHILDREN
K. Desloovere, C. Huenaerts, G. Molenaers, M. Eyssen, P. De Cock. Gait Analysis Laboratory, University Hospital Pellenberg, K. U. Leuven, Belgium
Introduction
Ankle-foot orthoses (AFOs) have been recommended for patients with cerebral palsy (CP) mairdy to correct an equinus gait pattern. A retrospective study was performed on diplegic and hemiplegic patients who had suitable barefoot and AFO gait trials on the same day. The objectives of the present study were to outline the effects of four different types of AF0s (conventional AFOs, fixed AF0s, hinged AFOs and leafsprmgs) on the walking patterns for CP children.
Methodology
Forty-seven children with CP, between the age of 5 and 12 years, participated to the study. The criteria for enrolment into the study were that the children had to be ambulant (no walking aids) with the diagnoses of spastic diplegia or spastic hemiplegla, that the children had been wearing the AFOs for at least two months and that an analysis of gait with and without AFOs was performed on the same day. Fifteen subjects (6 diplegic and 9 hemiplegic) wear conventional orthoses or klenzack (comprising a calfoand, double side steels and a mechanical joint aRaohed to the shoe), ten subjects (6 diplegic and 4 hemiplegic) wear leafsprings, seventeen subjects (11 dipleglc, 6 hemiplegic) wear hinged Polypropylene AFOs, and five subjects (3 diplegic and 2 hemiplegic) wear fixed polypropylene AFOs. A three dimensional gait analysis included kinematics and kinetics using a six camera VICON data capturing system and two AMTI force plates. The data were further processed using the Vicoo Clinical Manager software. Data analysis included comparison of the patients walking barefoot and with AFO, using a two-sample t-test. Variables fi'om kinematic (joint angles) and kinetic (moment and power) results were included in the analysis.
Results Use of an AFO during gait, as compared with the barefoot condition, produced a significant increase in stride length, a more pronounced knee flexion during loadin~ response, and a decrease of the pathological plantar-flexion/knee-exteesion couple. As expected, the ankle was more dorsiflexed at initial contact, and ankle plantar flexion at push offwas restricted. For patients with leafsprings and hinged AFOs, the above changes were accompanied with an increased hip extension at terminal stance and a decrease of hip abduction during swing. All subjects, except for those wearing conventional AFOs, showed a decreased excursion at the pelvis in the transversal plane. Despite of the more pronounced internal alignment of the feet during stance with AFOs as compared to barefoot walking, no effects of the AFO could be noticed on hip rotations. Fixed AFOs caused a more pronounced external knee extension moment during stance (GRF-effect)
were compared before and after botulinum toxin injection. Methodology [study i]: Eleven patients with a mean age of 5.4 (2.5-7.8) years and a follow up of 10.2 (6.8-12.6) years were included. All of them underwent achilles tendon lengthening by a percutanuous sliding technique. Recurrence was defined as a return to equinus leading to repeat lengthening. Results [study i]: Recurrance rate was 45.5%. Mean time between initial and repeat surgery was 5.2 (2.7-12.4) years. Methodology [study 2]: Eight patients with a mean of 4.9 (3.4-7.5) years were included. All of them received botulinum toxin injection in the gastrocnemius muscle. Gait analysis was performed with a mean of 59 (4-129) days before and 61 (42-79) after injection. A paired t test was used to compare the two results. Results [study 2]: Table included. Discussion: In this study with a long follow up the high recurrence rate found is very similar with that in literature. The results of botulinum toxin injection showed significant improvement of ankleflexion at initial contact (p<0.01). Maximum powergeneration during midstance was also reduced significantly (p<0.05). Maxim~impowergeneration during push-off was not changed. Explanation of these results is being discussed in this article. Further study with a longer follow up on treatment with bot~linum toxin and with involvement of the upper joints is necessary, but these results prove a potential for postponing surgery until the age of 7 years with less risk of recurrance. References i. Corry et al. Botulinum toxin A compared with stretching casts in the treatment of spastic equinus: a randomnised prospective trial. J Pediatr Orthop 1998;18:304-11. 2. Cosgrove et al. Botulinum toxin in the management of the lower limb in cerebral palsy. Dev Med Child Neurol 1994;36:386-96. 3. DeLuca. The muscleskeletal management of children with cerebral palsy. Pediatr Clin North Am 1996;43:1135-50. 4. Etnyre et al. Preoperative and postoperative assessment of surgical intervention for equinus gait in children with cerebral palsy. J Pediatr Orthop 1993;13:24-31. 5. Gage. Gait analysis in cerebral palsy. London:Mac Keith Press,1991:102-4,132-50. 6. Komau et al. Management of cerebral palsy with botulinumA toxin: preliminary investigation. J Pediatr Orthop 1993;13:489-95. 7. Olney et al. Work and power in hemiplegic cerebral palsy gait. Phys Thor 1990;70:431-38. 7. Rattey et el. Recurranee after achilles tendon lengthening in cerebral palsy. J Pediatr Orthop 1993;13:18487. 8. Rose et al. Kinematic and kinetic evaluation of the ankle after lengthening of the gastrocnemius fascia in children with cerebral palsy. J Pediatr Orthop 1993;13:727-32. 9. Sharrard et el. Zquinus deformity in cerebral palsy. J Bone Joint Surg;54B:272-76. I0. Yngve et al. Vulpius and Z-lengthening. J Pediatr Orthop 1996;16:759-64. Table Statistical comparison of pre- and postinjection measurements preinjection mean (SD) Velocity
Discussion and conclusion
View the conservative nature of orthotic devices, AFOs are commonly integrated into the management of different aspects associated with CP gait. This study illustrates the beneficial effects of the use of different AFOs on the gait pattern in CP children. Multiple significant effects on the ankle, but also on the proximal joints, were noticed. Comparing four bracing groups, some differences in effects on the gait pattern can be described. The lowest effect on pathological gait seemed to be associated with the use of the conventional AFO.
{m/s)
Steplengtb
(m)
p
1.10
(0.3)
11.08
(0.3)
0.8619
0.42
(0.i)
0.43
(0.1)
0.8411
(6)
-2
(7)
0.0093
I0 (4)
0.1071
Ankleflexion at Initial Contact (degr)
-ii
Maximum dorsiflexion during Stance (degr)
5 (8)
Maximum power generation during Midstanee (Watts/kg)
0.68
(0.6)
0.ii
(0.3)
0.0453
0.96
(0.5)
1.04
(0.6)
0.7960
IMaximum power igeneration during Push-Off (Watts/kg) Treatment of Equinus in Young Children with Hemiplegic Cerebral Palsy: Recurrance after Achilles Tendon Lengthening and Kinematic and Kinetic Evaluation of Treatment with Botulinum Toxin A.W.ZURCHER, G.MOLENAERS, G. FABRY (Pellenberg Hospital, Catholic University Leuven, Belgium) Abstract Introduction: When conservative treatment of equinus in children with cerebral palsy has failed, surgery is indicated performed by either gastrocnemius muscle or achilles tendon lengthening. Both Of these procedures carry a high risk of recurrance, especially in young children with hemiplegic cerebral palsy. In this article was studied the rate of recurrance after achilles tendon lengthening in this particular subgroup. Intramuscular botulinum toxin injection is a promising treatment which can postpone surgery. In a second study in this article kinematic and kinetic results
postinjection mean (SD)
THE LESION OF THE INTERVERTEBRAL DISCS IN MR IMAGE AND THE MOBILITY OF THE LUMBAR SECTION OF THE VERTEBRAL COLUMN MEASURED W I T H A PENNY & GILES ELECTROGONIOMETER.
P. Szulc, P.Bankowial% J.Lewandowski Department of Functional Anatomy, University School of Physical Education, Poznaft, Poland