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Clinical applications and future research horizons
ABSTRACTS Proceedings of the third annual conference of the European Society Movement Analysis in Children, Enschede, The Netherlands 27-30
October
of
1995
Clinical applications and future research horizons D H Sutherland
Department of Orthopaedics, University of California, San Diego, California; Motion Analysis Laboratory Children’s Hospital, San Diego, CA, USA The clinical use of motion analysis in myelomeningocele (MMC) has lagged behind its use in cerebral palsy. Many newly opened, and a number of well-established laboratories are now performing clinical assessment of patients with MMC. We can look for improvements in patient care with MMC, just as improvements have been brought about in the management of patients with cerebral palsy. A review of the literature of gait analysis contributions in MMC reveals that some progress has been made. The outcome of surgical procedures has been studied, orthoses have been evaluated, and energy studies have compared energy expenditures with various orthoses and wheelchair mobility. An example of the use of gait analysis in the evaluation of surgical procedures is the article by Banta et al. [l], reporting the beneficial effect of transfer of the tibialis anterior to the OScalcis for calcaneal gait. By contrast, a lack of muscle phase conversion was reported and a frequent need for subsequent operative procedures in their series of patients treated by posterior transfer of the tibialis anterior. Additional studies are needed to resolve this issue. An example of energy studies is the article by Lough & Nielsen [2] comparing the parapodium and parapodium with Orlau swivel modification. The conclusions drawn from the study were that the walking velocity was higher with the parapodium but energy costs and gait efficiency were better with the swivel walker. In another energy related gait study, it was reported that the energy cost of walking with the Reciprocating Gait Orthosis was not greater than with wheelchair ambulation. Vankoski et al. [3], compared the dynamic joint angle measurements of pelvis, hip and knee in two groups of patients with MMC. Both groups had lumbosacral level myelomeningocele. The distinguishing feature was the presence of plantar flexor motor strength in one group and absence of the same in the other group. Increased anterior pelvic tilt was present in the patients requiring
orthoses. Increased pelvic rotation and increased pelvic obliquity were found in the patients with the greatest weakness. The conclusion was reached that kinematic gait abnormalities correlated well with the level of motor deficiency. Patients with lower lumbar and sacral level lesions often require only ankle/foot orthoses while those with higher level defects need more elaborate orthotic devices in order to walk. Upright posture and ambulation are valuable initially for most patients however, only l/3 of high functional deficit subjects will continue functional ambulation. The Reciprocating Gait Orthosis (RGO), first developed by Motlock, has been widely accepted and used to make ambulation possible for patients with thoracic and upper lumbar level lesions. The competitor of the RGO is the Hip Guidance Orthosis (HGO), developed by Rose [4,5]. Both systems, to some degree, use weight shifting and gravity to stabilize the hip and advance the swinging leg. Research is needed to answer a number of questions. Does the RGO increase stride length over the HGO? How much force is applied through the upper extremities to walker or crutches with both orthotic systems? Gait analysis holds the key to answering these and similar questions. The remarkable improvements in orthoses which have been made do not begin to exhaust the possibilities for technical advances. We should not be content to provide orthoses that do not allow the natural movement of knee flexion in swing phase. We have developed an experimental electronically controlled automatic knee release orthosis in our laboratory. I think it likely that this orthosis can be combined with an RGO to provide more natural walking for patients with thoracic and upper lumbar level MMC. We have not as yet attempted this combination. A video demonstration of the orthosis will be shown. The use of external power at the ankle is another possibility which should not be ruled out. In conclusion, the role of gait analysis for myelomeningocele is to provide a foundation of objective assessment for pre and postoperative clinical evaluations, outcome studies, and orthotic development. Well designed clinical and research protocols, multidisciplinary collaboration, and much hard work will be need-
Abstracts
ed to further improve mobility and the quality of life for patients with myelomeningocele. References
Banta J V, SutherlandD H, Wyatt M. Anterior Tibia1 Transfer to the OS Calcis with Achilles Tenodesisfor CalcanealDeformity in Myelomeningocele.J Pediatr Orthop New York: Raven Press,1981;1: 125-130. Lough L, Nielsen D. Ambulation Of Children With Myelomeningocele: Parapodium Versus Parapodium With Orlau Swivel Modification. Develop Med Child Neural 1986;28: 489-497. Vankoski S J, Sarwark J F, Moore C, Dias L. Characteristicpelvic, hip, and kneekinematicpatternsin childrenwith lumbosacralmyelomeningocele. Gait & Posture March 1995;3(l): 51-57. RoseG K, Stallard J, Sankarankutty M. Clinical Evaluation of Spina Bilida Patients Using Hip guidanceOrthosis.Develop Med Child Neurol 1981;23: 30-40. RoseG K, Sankarankutty M, Stallard J. A Clinical Review Of The Orthotic Treatment Of Myelomeningocele Patients. J Bone Joint Surg 1983;65B(3):242-246. Further Reading BeatyJ H, CanaleST. Current ConceptsReviewOrthopaedic Aspectsof Myelomeningocele.J Bone Joint Surg 1990. Carroll N. The Orthotic Managementof the Spina Bitida Child. Cfin Orthop & Ref Res 1974;102: 108-114. Carroll N C. Assessment and Managementof the Lower Extremity in Myelodysplasia. Orthop Clin N A 1987; 18(4) 709-724. CharneyE B, Melchionni J B, Smith D R. Community Ambulation by Childrenwith Myelomeningoceleand High-Level Paralysis.J Pediatr Orthop New York: Raven Press,1991;11: 579-582. DeSouzaL, Carroll N. Ambulation of the BracedMyelomeningocelePatient. J Bone Joint Surg 58A:8 1112-1118,1976. Fulford GE, CairnsTP. The ProblemsAssociatedWith Flail Feet In ChildrenAnd Their TreatmentWith Orthoses.J Bone Joint Surg 1978;60B(l): 93-95. Feiwell E, SakaiD, Blatt T. The Effect of Hip Reductionon Function in Patients with Myelomeningocele.J Bone Joint Surg 1978;6OA(2): 169-172. Hullin M G, Robb J E, Loudon I R. Ankle-Foot Orthosis Function in Low-Level Myelomeningocele.J Pediatr Orthop, New York: Raven Press,1992;12: 518-521. LindsethR, Glancy J. PolypropyleneLower-Extremity Braces for ParaplegiaDue to Myelomeningocele.J Bone Joint Surg 1974;56A(3): 556-563. McCall R E, Schmidt W T. Clinical Experiencewith the ReciprocalGait Orthosisin Myelodysplasia.J Pediatr Orthop 1986;6(2): 157-161. Stillwell A, MenelausM. Walking Ability in Mature Patients with SpinaBifida. J Pediatr Orthop, New York: Raven Press, 1983;3: 184-190. SutherlandD H. An electromyographicstudy of the plantar flexors of the ankle in normal walking on the level. J Bone Joint Surg 1966;48A: 66-71. SutherlandD H, CooperDanielD. The role of the ankleplantar flexors in normal walking. J Bone Joint Surg 1980;62A: 336-353. Swank M, Dias L. Myelomeningocele:A Review Of The OrthopaedicAspectsof 206PatientsTreatedFrom Birth with
271
No SelectionCriteria. Develop Med Child Neural 1992;34: 1047-1052. Yngve D, Douglas R, Roberts J. The ReciprocatingGait Orthosisin Myelomeningocele.J Pediatr Orthop, New York: Raven Press,1984;4: 304-310. Prospective study of gait maturation in normal children
A M Mann, I R Loudon, A M Lawson, J E Robb, C B Meadows Princess Margaret Rose Orthopaedic Hospital, Edinburgh; Health Care International, Clydebank This is an initial report on one aspect of a long-term study of the maturation of the kinetic aspects of gait in a group of forty normal children. Sutherland [l] suggested that most gait parameters had matured in children by the age of live years and Ounpuu et al. [2] found that the kinetic pattern of children’s gait was mature before the age of five. This paper looks at one fundamental parameter, the magnitude of the second peak of the vertical component of the ground reaction force (FZ,). There are good biomechanical reasons for supposing that failure of FZz to exceed body weight indicates that the subject is collapsing, their body accelerating and that the gait pattern is poorly controlled. Meadows [3] associated this feature of gait in children with cerebral palsy with muscular weakness and excessive external joint moments. He also showed a relationship between corrected, more controlled gait and a recovery of FZz to exceed body weight. Method
Fifty three normal children were analysed using a Vicon system with Kistler force plate. This three dimensional analysis was repeated with the same children each year for four years. Thirteen of the children left the study during the four years and were lost to follow-up. Results
FZz did not exceed body weight in 16% of five year old children, 12% of six year olds, 11% of seven year olds and 13% of eight year olds. 8% of the subject group consistently failed to exceed body weight. These results lead to the conclusions that: (a) Failure of FZ2 to exceed body weight is not necessarily an indicator of pathological gait in some live to eight year old children.
October
of
1995
Clinical applications and future research horizons D H Sutherland
Department of Orthopaedics, University of California, San Diego, California; Motion Analysis Laboratory Children’s Hospital, San Diego, CA, USA The clinical use of motion analysis in myelomeningocele (MMC) has lagged behind its use in cerebral palsy. Many newly opened, and a number of well-established laboratories are now performing clinical assessment of patients with MMC. We can look for improvements in patient care with MMC, just as improvements have been brought about in the management of patients with cerebral palsy. A review of the literature of gait analysis contributions in MMC reveals that some progress has been made. The outcome of surgical procedures has been studied, orthoses have been evaluated, and energy studies have compared energy expenditures with various orthoses and wheelchair mobility. An example of the use of gait analysis in the evaluation of surgical procedures is the article by Banta et al. [l], reporting the beneficial effect of transfer of the tibialis anterior to the OScalcis for calcaneal gait. By contrast, a lack of muscle phase conversion was reported and a frequent need for subsequent operative procedures in their series of patients treated by posterior transfer of the tibialis anterior. Additional studies are needed to resolve this issue. An example of energy studies is the article by Lough & Nielsen [2] comparing the parapodium and parapodium with Orlau swivel modification. The conclusions drawn from the study were that the walking velocity was higher with the parapodium but energy costs and gait efficiency were better with the swivel walker. In another energy related gait study, it was reported that the energy cost of walking with the Reciprocating Gait Orthosis was not greater than with wheelchair ambulation. Vankoski et al. [3], compared the dynamic joint angle measurements of pelvis, hip and knee in two groups of patients with MMC. Both groups had lumbosacral level myelomeningocele. The distinguishing feature was the presence of plantar flexor motor strength in one group and absence of the same in the other group. Increased anterior pelvic tilt was present in the patients requiring
orthoses. Increased pelvic rotation and increased pelvic obliquity were found in the patients with the greatest weakness. The conclusion was reached that kinematic gait abnormalities correlated well with the level of motor deficiency. Patients with lower lumbar and sacral level lesions often require only ankle/foot orthoses while those with higher level defects need more elaborate orthotic devices in order to walk. Upright posture and ambulation are valuable initially for most patients however, only l/3 of high functional deficit subjects will continue functional ambulation. The Reciprocating Gait Orthosis (RGO), first developed by Motlock, has been widely accepted and used to make ambulation possible for patients with thoracic and upper lumbar level lesions. The competitor of the RGO is the Hip Guidance Orthosis (HGO), developed by Rose [4,5]. Both systems, to some degree, use weight shifting and gravity to stabilize the hip and advance the swinging leg. Research is needed to answer a number of questions. Does the RGO increase stride length over the HGO? How much force is applied through the upper extremities to walker or crutches with both orthotic systems? Gait analysis holds the key to answering these and similar questions. The remarkable improvements in orthoses which have been made do not begin to exhaust the possibilities for technical advances. We should not be content to provide orthoses that do not allow the natural movement of knee flexion in swing phase. We have developed an experimental electronically controlled automatic knee release orthosis in our laboratory. I think it likely that this orthosis can be combined with an RGO to provide more natural walking for patients with thoracic and upper lumbar level MMC. We have not as yet attempted this combination. A video demonstration of the orthosis will be shown. The use of external power at the ankle is another possibility which should not be ruled out. In conclusion, the role of gait analysis for myelomeningocele is to provide a foundation of objective assessment for pre and postoperative clinical evaluations, outcome studies, and orthotic development. Well designed clinical and research protocols, multidisciplinary collaboration, and much hard work will be need-
Abstracts
ed to further improve mobility and the quality of life for patients with myelomeningocele. References
Banta J V, SutherlandD H, Wyatt M. Anterior Tibia1 Transfer to the OS Calcis with Achilles Tenodesisfor CalcanealDeformity in Myelomeningocele.J Pediatr Orthop New York: Raven Press,1981;1: 125-130. Lough L, Nielsen D. Ambulation Of Children With Myelomeningocele: Parapodium Versus Parapodium With Orlau Swivel Modification. Develop Med Child Neural 1986;28: 489-497. Vankoski S J, Sarwark J F, Moore C, Dias L. Characteristicpelvic, hip, and kneekinematicpatternsin childrenwith lumbosacralmyelomeningocele. Gait & Posture March 1995;3(l): 51-57. RoseG K, Stallard J, Sankarankutty M. Clinical Evaluation of Spina Bilida Patients Using Hip guidanceOrthosis.Develop Med Child Neurol 1981;23: 30-40. RoseG K, Sankarankutty M, Stallard J. A Clinical Review Of The Orthotic Treatment Of Myelomeningocele Patients. J Bone Joint Surg 1983;65B(3):242-246. Further Reading BeatyJ H, CanaleST. Current ConceptsReviewOrthopaedic Aspectsof Myelomeningocele.J Bone Joint Surg 1990. Carroll N. The Orthotic Managementof the Spina Bitida Child. Cfin Orthop & Ref Res 1974;102: 108-114. Carroll N C. Assessment and Managementof the Lower Extremity in Myelodysplasia. Orthop Clin N A 1987; 18(4) 709-724. CharneyE B, Melchionni J B, Smith D R. Community Ambulation by Childrenwith Myelomeningoceleand High-Level Paralysis.J Pediatr Orthop New York: Raven Press,1991;11: 579-582. DeSouzaL, Carroll N. Ambulation of the BracedMyelomeningocelePatient. J Bone Joint Surg 58A:8 1112-1118,1976. Fulford GE, CairnsTP. The ProblemsAssociatedWith Flail Feet In ChildrenAnd Their TreatmentWith Orthoses.J Bone Joint Surg 1978;60B(l): 93-95. Feiwell E, SakaiD, Blatt T. The Effect of Hip Reductionon Function in Patients with Myelomeningocele.J Bone Joint Surg 1978;6OA(2): 169-172. Hullin M G, Robb J E, Loudon I R. Ankle-Foot Orthosis Function in Low-Level Myelomeningocele.J Pediatr Orthop, New York: Raven Press,1992;12: 518-521. LindsethR, Glancy J. PolypropyleneLower-Extremity Braces for ParaplegiaDue to Myelomeningocele.J Bone Joint Surg 1974;56A(3): 556-563. McCall R E, Schmidt W T. Clinical Experiencewith the ReciprocalGait Orthosisin Myelodysplasia.J Pediatr Orthop 1986;6(2): 157-161. Stillwell A, MenelausM. Walking Ability in Mature Patients with SpinaBifida. J Pediatr Orthop, New York: Raven Press, 1983;3: 184-190. SutherlandD H. An electromyographicstudy of the plantar flexors of the ankle in normal walking on the level. J Bone Joint Surg 1966;48A: 66-71. SutherlandD H, CooperDanielD. The role of the ankleplantar flexors in normal walking. J Bone Joint Surg 1980;62A: 336-353. Swank M, Dias L. Myelomeningocele:A Review Of The OrthopaedicAspectsof 206PatientsTreatedFrom Birth with
271
No SelectionCriteria. Develop Med Child Neural 1992;34: 1047-1052. Yngve D, Douglas R, Roberts J. The ReciprocatingGait Orthosisin Myelomeningocele.J Pediatr Orthop, New York: Raven Press,1984;4: 304-310. Prospective study of gait maturation in normal children
A M Mann, I R Loudon, A M Lawson, J E Robb, C B Meadows Princess Margaret Rose Orthopaedic Hospital, Edinburgh; Health Care International, Clydebank This is an initial report on one aspect of a long-term study of the maturation of the kinetic aspects of gait in a group of forty normal children. Sutherland [l] suggested that most gait parameters had matured in children by the age of live years and Ounpuu et al. [2] found that the kinetic pattern of children’s gait was mature before the age of five. This paper looks at one fundamental parameter, the magnitude of the second peak of the vertical component of the ground reaction force (FZ,). There are good biomechanical reasons for supposing that failure of FZz to exceed body weight indicates that the subject is collapsing, their body accelerating and that the gait pattern is poorly controlled. Meadows [3] associated this feature of gait in children with cerebral palsy with muscular weakness and excessive external joint moments. He also showed a relationship between corrected, more controlled gait and a recovery of FZz to exceed body weight. Method
Fifty three normal children were analysed using a Vicon system with Kistler force plate. This three dimensional analysis was repeated with the same children each year for four years. Thirteen of the children left the study during the four years and were lost to follow-up. Results
FZz did not exceed body weight in 16% of five year old children, 12% of six year olds, 11% of seven year olds and 13% of eight year olds. 8% of the subject group consistently failed to exceed body weight. These results lead to the conclusions that: (a) Failure of FZ2 to exceed body weight is not necessarily an indicator of pathological gait in some live to eight year old children.