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Comparative study of conventional hip knee ankle foot orthoses versus reciprocating gait orthoses in pediatric patients
Abstracts
CHARACTERISTIC PELVIC, HIP AND KNEE KINEMATIC PATTERNS IN CHILDREN WITH LUMBO-SACRAL MYELOMENINGOCELE Steehen J. V&~&o&i MS, John F. Sanvark MD, Carolyn Moore BSc, Luciano Diaa MD. Children’s Memorial Hospital, Chicago, Illinois.
EXAMINATION OF INTERSEGMENTAL COORDINATION IN SPASTIC CEREBRAL PALSY PATIENTS BEFORE AND AFI’ER SELECl-lVE POSTERIOR
Tbe purpose of this study was to distinguish characteristic gait patterns in children with lumbo-sacral level myelomeningocele. Twenty one patients were evaluated using gait analysis. There were 7 males and 14 females with a mean age of 8.4 years, ranging from 4 - 15 years. All patients could walk independently, although some used ortbotica. A manual muscle test was performed using a conventional letter grading system. Numerical values were assigned ta the letter grades to allow for a convenient comparison of muscle strength. The patients were divided into two gwupa based upon presence (group I) or absence (pup II) of muscle strength for the gastrocnemiua. Group I patienta were further subdivided baaed upon whether they walked both with and without AFOs or they walked exclusively without AFOs. Kinematic patterns were analyzed for the pelvis, hip, and knee.
Joint angle-angk diagrams of lower limb kinematics have been used to evaloatc joint movement in ncomlogically involved patients. Joint angle trajcctorics arc recorded daring gait and then plotted against each other to form a cyclic paacm for each stride. The digrams can bc compared to normal and allow for recognition and analysis of both normal axI pathological gait pattam, as well as the examination of intcrscgmcntal coordination. Cxcbral palsy (CP) is a maltifacctcd disorder including spa&city, weakness, incoordination, and impaired s&ctivc motor control of the limbs. Surgical rcdoction of spasticity cao bc bcnef~cial through selstive posterior rhizotomy (SPR). Soccwsfol outcome following SPR is dependent on sclcction of candiiatcs with disabling spa&city who also demonshate miaii involvement ia areas of strength and motor control. However. there arc few objcctivc methods for the evaluation of spczitic features of CP. ‘fhe porpasc of this study was to examine the uscfulncss of angleangle diagrams as an outcome measure in patients with spastic CP undergoing SPR with a specific focus on the evaluation of plot shape and area as indicamn of inters.egmatal coordiition. Five childmn, ages S-12 (mean = 7.9): with spastic diplegia who walked independently wcrc studied. For companson, normal data were colkctcd on eight subjects, ages 4.5-21 (meao = 8.2). Movement was vidcotapzd at 30 HZ.and threedimnsiooal kinematics were obcaincd by digitizing joint markers using an iateractive sofhvare system. Angle-angle diagrams of sagittal plant hip vs. knu motion wm constmctcd for normal sobjccts and for CP paricnts both prcwgically and 7-14 months postsurgically. The featarcs examined in thcac diagrams wcrc: 1) the cncloscd area and 2) the shape. Additionally, the total joint excursion or range of motion (ROM) at the hip and kaee was measured. Comparisons were then made between normal aad CP subjccts. Area was expressive of the mtal conjoint range of angular motion occorriog at the hip and knee joints during one complctc gait cycle. The mean arw of the angle-angle plots incrcascd significantly from 584.46 degtprcoperatively to 1005.21 deg* postoperatively @ < .Oal). The mean area for normal subjccw was 1272.64 a$. Normaliition of the plot shape, which indicates impmvcd interscgmcnral control and coordination between joints, was demonstrated in all cases. For exampk, the ability to hold the hip constant while extcnding the knee during the tcnninal swing phase of gait prescntcd graphically as a rclativcly straight vertical line. The ROM at both the hip and kna joints after surgcxy showed a significant iwrcasc towards normal @ < .Ol). This pilot study suggests that angle-angk diagrams arc a useful tool for evaluating changes in intersegmental control and coordination behvcen lower limb joints in spastic CP patients following surgical intervention. This method provides an advantage 0vc.r a simple time-series kinematics evaluation. wbcrc joint angles are plottcd versus time. bxause it allows visualization and qoantification of the interplay bctwcen joints. Because of the complex nature of CP, methods which &dress intusegmntal coordination as well as other feanucs of motor function arc valuable as outcome and potential prognostic measures for patients undergoing SPR and other ticatment interventions for CP.
The tibialis anterior, gastrocnemius, gluteus maximus, and gluteus medius were weaker in Group II when compared to Group I (p < 0.01). Distinguishable kinematic patterns were identified. Pelvic tilt showed an increased excursion in Group II. The use of AFOs during ambulation increased the anterior pelvic tilt in both groups. Pelvic obliquity and rotation exhibited a progressive increase in dynamic range of motion fmm Gmup I to Group II. No significant deviations from the normal pattern were observed for hip flexion/extension. Increased hip abduction was observed in initial stance and mid to terminal swing in those patients who commonly wore AFOs. Increased knee flexion during stance wae seen in Group I and Gmup II. Improved mid stance knee extension was observed in both gmups for the APO conditions. Knee flexion during the swing phase was within normal limits for Group I. Gmup II patients displayed decreased knee flexion during the swing phase. The results showed that deviations in the patterns were most apparent at the pelvis and knee and were related to muscle weakness. The compensatory kinematic patterns described allow these patients to maintain independent and functional ambulation. The identification of these kinematic patterns is the first step towards establishing a framework from wbicb improved evaluation and treatment of this patient population can be realized.
COMPARATlVE STUDY OF CONVENTIONAL HIP KNEE ANKLE FOOT ORTHOSES VERSUS RECIPROCATING GAIT ORTHOSES IN PEDIATRIC PATIENTS Nasreen Haideri. M&‘, Donald Katz, CO.‘. Phil Wyrick, B.S.‘, Cecilia Concha, B.S.‘, Kit Song, M.D.’ ‘Texas Scottish Rite Hospital for Children, Dallas, TX ‘St. Paul Human Performance Center, Dallas, TX The purpose of this project was to assess the value of reciprocating gait orthoses for patients with high level (3 or greater) myelodysplasia. In addition, we evaluated several methods for approximating energy expenditure in this population. Eight patients (3M/SF)were recruited from the Spina Bifida Clinic at Texas Scottish Rite Hospital for Children. Of the eight patients, four had thoracic level lesions and four had lumbar level lesions. Selection criteria required all patients to have plantargrade feet or mild equinous, hips and knees free of significant contractwe (less than 20 deg.) with hips flexible, not rigid or spastic. All patients had good upper extremity strength, at least 4/5 for key crutch muscles, and were capable of a seated push up and hold for 60 sets. All were motivated and compliant. Average age was 7 + 1 (range 4 +2 through 11 +2) at time of enrollment. All of the patients underwent routine clinical treatment at the Orthotics Clinic at TSRHC and were fitted with both conventional HKAFO’s and Isocentric Reciprocating Gait Orthoses (Center for Orthotic Design, Redwood City, CA). The same KAFO section was used for both pairs of orthoses. After a six week adaptation period, each patient’s ambulation was assessed using metabolic and cadence parameters, and a subjective questionnaire was completed by the patient and their family. Metabolic measurements were obtained at rest and during ambulation by the Douglas bag technique, which analyzed oxygen consumption and carbon dioxide production utilizing a Perkin-Elmer 1100 mass spectrometer and a Tissot Spirometer for ventilatory volumes. For the entire group, the mean 0, cost in HKAFO’s was greater than the mean 0, cost in RGO’s (p =.03). For the four thoracic level patients, the relative 0, cost was greater using HKAFO’s (p =.OCKl7);however, no difference was seen for the four lumbar level patients. The relative mean increase in heart rate from rest using HKAFO’s was greater than the mean increase using RGO’s (p=O.O2). The relative velocity showed that the RGO’s were faster than the HKAFO’s (p=.O4). Correlations were computed between the measured 0, cost. calculated 0, cost, physiologic cost index (PCI), velocity, and heart rate. Calculated 0, cost was found to correlate best with measured 0, cost, r=.88 (p=.OCt4). PC1 correlated with measured 0, cost, r=.83 (p=.Ol). Velocity correlated inversely with r=.87 (p =.006). There was a positive correlation of heart rate measurement with measured 0, cost; however it was not statistically significant.
BA: Lorctta Staud~ MS, PT; Eileen Fowla, PHD, PT; Alan Garfinkel, PHD: and Warwick Peacock, MD; University of California, Los Angeles
HIP FUNCl’lON IN CEREBRAL PALSY -THE KINEMATIC AND KINEl?C m OF PSOAS SURGERY Chin Y. Chung, MD, Tpm F. Nm James R. Gage. MD Motion Amlysis Lab, Gil!-ctte Childn& Hospital To evaluate the effects of sorcery on the hip in patients with cexcbml palsy, this study was ondertakm at the won Analysis I&onwry at Gillotte children s Hospital. In fmticular the changes dw to psoas kngthming over the brim of the pelvis were assessed The study group consisted of 34 subjects (48 sides) that had adeq~pwpaativeandpostop?mdvekinemuticandkinelicdataaMilablefor comparison. In addition, the study group wps compared to a antml gmup of 13 ments (14 sides) who underwent a comparable set of swgeries with the aception that ?o _ surgery was performed. Each of the patim& in both gmops underwent molhple other pmcedorcs under the same me&&. The Vioon Clinical Manager wasuscdtopmcesstidata ‘Ihe prrapaative kinematic status of the study and control groups w slightly different consistmt titttthcpmapwiwdccisioo-makingregdK8ng psas lcngthexdag. ‘f&peak (229 and minimum (139 anterior pelvic tilt was ioawaed in thestudygmupmmpsrsdtonamalbutnotintheconhds(n~nluespel3o and 1 lo mapeztlvely). Hip motion was skewed toward flexion in both gmops but to agmaterextmtinthcstudygrcup. Tbarwasiwmasrdpeakhipfkxi~~inboth gmops (43” vs 420) at initial contact (ncrmai 35”) and duxascd peak hip extension (1o”vs l”fkxion)inpwwing(normalPextm.5ion). Postqxzatively, in UK study gmop, all of these valuee significantl improved toward normal -tin8 an impmvemcnt in their crouch gait pattan. -!hUE?, ccmeapmding preopntive &v&ions in the$ody groap b&ding M inaeased peak hip extensor mnaeat (0.82 Nmikg) whxh occorred later in the gait cycle (13%) than normal (0.48 Nm& 8 4%). The hip moment cnwmw pointfmn~~tofl~w~~~~~~~4l%of the ‘t cyck @rmal = 24%). ‘lbe peak hip fkxor moment ~0s similar1 daxeaxd (O.SGmn;s) and atlayed (56%) ccmpared to norm& (l.aSNmllrg 0 $246). f’ost+ratively, all of thee values wae significantly improved io both groups but moresointbestodygmup. Jnadditkm,tbetotaIextenaormommtandtaalflexor moment were improved with _ surgery. Tlle.v&ttalplaoepwaealaoalmamal prropaatively in both the control and shady gmups. Ihe power Baaption and absmp&m wem diminished in bpth upscomparedtonoimah. h@paatively,tkeHIgateratioapeakwas s1gnlz”caatly dcarar+d in t&e study group (0.12 to 0.05 J ) implying less hip flexor donunamz Ihe H2 absorption peak bwcawd (0.?z to 0.05 J/kg), but ~_~~~~Y. the H3 hi p fl exoI power genera& was not diminished These patientswere found !o have statisticallyincmascd walking velocity @ldi-OXygeo~sndOXygLYtCOStrrvcalingovcnll qnwematt in the&walking timction with surgical intavention. This sudy shows ~slrrgicPlintaveationincl~psoarlengtbeningava~brimofthepelvis significantlyimproves hip kiwnatks and kineticsin nearly alI aspects without sacrificinghip tlexor power guwaticm.
61
CHARACTERISTIC PELVIC, HIP AND KNEE KINEMATIC PATTERNS IN CHILDREN WITH LUMBO-SACRAL MYELOMENINGOCELE Steehen J. V&~&o&i MS, John F. Sanvark MD, Carolyn Moore BSc, Luciano Diaa MD. Children’s Memorial Hospital, Chicago, Illinois.
EXAMINATION OF INTERSEGMENTAL COORDINATION IN SPASTIC CEREBRAL PALSY PATIENTS BEFORE AND AFI’ER SELECl-lVE POSTERIOR
Tbe purpose of this study was to distinguish characteristic gait patterns in children with lumbo-sacral level myelomeningocele. Twenty one patients were evaluated using gait analysis. There were 7 males and 14 females with a mean age of 8.4 years, ranging from 4 - 15 years. All patients could walk independently, although some used ortbotica. A manual muscle test was performed using a conventional letter grading system. Numerical values were assigned ta the letter grades to allow for a convenient comparison of muscle strength. The patients were divided into two gwupa based upon presence (group I) or absence (pup II) of muscle strength for the gastrocnemiua. Group I patienta were further subdivided baaed upon whether they walked both with and without AFOs or they walked exclusively without AFOs. Kinematic patterns were analyzed for the pelvis, hip, and knee.
Joint angle-angk diagrams of lower limb kinematics have been used to evaloatc joint movement in ncomlogically involved patients. Joint angle trajcctorics arc recorded daring gait and then plotted against each other to form a cyclic paacm for each stride. The digrams can bc compared to normal and allow for recognition and analysis of both normal axI pathological gait pattam, as well as the examination of intcrscgmcntal coordination. Cxcbral palsy (CP) is a maltifacctcd disorder including spa&city, weakness, incoordination, and impaired s&ctivc motor control of the limbs. Surgical rcdoction of spasticity cao bc bcnef~cial through selstive posterior rhizotomy (SPR). Soccwsfol outcome following SPR is dependent on sclcction of candiiatcs with disabling spa&city who also demonshate miaii involvement ia areas of strength and motor control. However. there arc few objcctivc methods for the evaluation of spczitic features of CP. ‘fhe porpasc of this study was to examine the uscfulncss of angleangle diagrams as an outcome measure in patients with spastic CP undergoing SPR with a specific focus on the evaluation of plot shape and area as indicamn of inters.egmatal coordiition. Five childmn, ages S-12 (mean = 7.9): with spastic diplegia who walked independently wcrc studied. For companson, normal data were colkctcd on eight subjects, ages 4.5-21 (meao = 8.2). Movement was vidcotapzd at 30 HZ.and threedimnsiooal kinematics were obcaincd by digitizing joint markers using an iateractive sofhvare system. Angle-angle diagrams of sagittal plant hip vs. knu motion wm constmctcd for normal sobjccts and for CP paricnts both prcwgically and 7-14 months postsurgically. The featarcs examined in thcac diagrams wcrc: 1) the cncloscd area and 2) the shape. Additionally, the total joint excursion or range of motion (ROM) at the hip and kaee was measured. Comparisons were then made between normal aad CP subjccts. Area was expressive of the mtal conjoint range of angular motion occorriog at the hip and knee joints during one complctc gait cycle. The mean arw of the angle-angle plots incrcascd significantly from 584.46 degtprcoperatively to 1005.21 deg* postoperatively @ < .Oal). The mean area for normal subjccw was 1272.64 a$. Normaliition of the plot shape, which indicates impmvcd interscgmcnral control and coordination between joints, was demonstrated in all cases. For exampk, the ability to hold the hip constant while extcnding the knee during the tcnninal swing phase of gait prescntcd graphically as a rclativcly straight vertical line. The ROM at both the hip and kna joints after surgcxy showed a significant iwrcasc towards normal @ < .Ol). This pilot study suggests that angle-angk diagrams arc a useful tool for evaluating changes in intersegmental control and coordination behvcen lower limb joints in spastic CP patients following surgical intervention. This method provides an advantage 0vc.r a simple time-series kinematics evaluation. wbcrc joint angles are plottcd versus time. bxause it allows visualization and qoantification of the interplay bctwcen joints. Because of the complex nature of CP, methods which &dress intusegmntal coordination as well as other feanucs of motor function arc valuable as outcome and potential prognostic measures for patients undergoing SPR and other ticatment interventions for CP.
The tibialis anterior, gastrocnemius, gluteus maximus, and gluteus medius were weaker in Group II when compared to Group I (p < 0.01). Distinguishable kinematic patterns were identified. Pelvic tilt showed an increased excursion in Group II. The use of AFOs during ambulation increased the anterior pelvic tilt in both groups. Pelvic obliquity and rotation exhibited a progressive increase in dynamic range of motion fmm Gmup I to Group II. No significant deviations from the normal pattern were observed for hip flexion/extension. Increased hip abduction was observed in initial stance and mid to terminal swing in those patients who commonly wore AFOs. Increased knee flexion during stance wae seen in Group I and Gmup II. Improved mid stance knee extension was observed in both gmups for the APO conditions. Knee flexion during the swing phase was within normal limits for Group I. Gmup II patients displayed decreased knee flexion during the swing phase. The results showed that deviations in the patterns were most apparent at the pelvis and knee and were related to muscle weakness. The compensatory kinematic patterns described allow these patients to maintain independent and functional ambulation. The identification of these kinematic patterns is the first step towards establishing a framework from wbicb improved evaluation and treatment of this patient population can be realized.
COMPARATlVE STUDY OF CONVENTIONAL HIP KNEE ANKLE FOOT ORTHOSES VERSUS RECIPROCATING GAIT ORTHOSES IN PEDIATRIC PATIENTS Nasreen Haideri. M&‘, Donald Katz, CO.‘. Phil Wyrick, B.S.‘, Cecilia Concha, B.S.‘, Kit Song, M.D.’ ‘Texas Scottish Rite Hospital for Children, Dallas, TX ‘St. Paul Human Performance Center, Dallas, TX The purpose of this project was to assess the value of reciprocating gait orthoses for patients with high level (3 or greater) myelodysplasia. In addition, we evaluated several methods for approximating energy expenditure in this population. Eight patients (3M/SF)were recruited from the Spina Bifida Clinic at Texas Scottish Rite Hospital for Children. Of the eight patients, four had thoracic level lesions and four had lumbar level lesions. Selection criteria required all patients to have plantargrade feet or mild equinous, hips and knees free of significant contractwe (less than 20 deg.) with hips flexible, not rigid or spastic. All patients had good upper extremity strength, at least 4/5 for key crutch muscles, and were capable of a seated push up and hold for 60 sets. All were motivated and compliant. Average age was 7 + 1 (range 4 +2 through 11 +2) at time of enrollment. All of the patients underwent routine clinical treatment at the Orthotics Clinic at TSRHC and were fitted with both conventional HKAFO’s and Isocentric Reciprocating Gait Orthoses (Center for Orthotic Design, Redwood City, CA). The same KAFO section was used for both pairs of orthoses. After a six week adaptation period, each patient’s ambulation was assessed using metabolic and cadence parameters, and a subjective questionnaire was completed by the patient and their family. Metabolic measurements were obtained at rest and during ambulation by the Douglas bag technique, which analyzed oxygen consumption and carbon dioxide production utilizing a Perkin-Elmer 1100 mass spectrometer and a Tissot Spirometer for ventilatory volumes. For the entire group, the mean 0, cost in HKAFO’s was greater than the mean 0, cost in RGO’s (p =.03). For the four thoracic level patients, the relative 0, cost was greater using HKAFO’s (p =.OCKl7);however, no difference was seen for the four lumbar level patients. The relative mean increase in heart rate from rest using HKAFO’s was greater than the mean increase using RGO’s (p=O.O2). The relative velocity showed that the RGO’s were faster than the HKAFO’s (p=.O4). Correlations were computed between the measured 0, cost. calculated 0, cost, physiologic cost index (PCI), velocity, and heart rate. Calculated 0, cost was found to correlate best with measured 0, cost, r=.88 (p=.OCt4). PC1 correlated with measured 0, cost, r=.83 (p=.Ol). Velocity correlated inversely with r=.87 (p =.006). There was a positive correlation of heart rate measurement with measured 0, cost; however it was not statistically significant.
BA: Lorctta Staud~ MS, PT; Eileen Fowla, PHD, PT; Alan Garfinkel, PHD: and Warwick Peacock, MD; University of California, Los Angeles
HIP FUNCl’lON IN CEREBRAL PALSY -THE KINEMATIC AND KINEl?C m OF PSOAS SURGERY Chin Y. Chung, MD, Tpm F. Nm James R. Gage. MD Motion Amlysis Lab, Gil!-ctte Childn& Hospital To evaluate the effects of sorcery on the hip in patients with cexcbml palsy, this study was ondertakm at the won Analysis I&onwry at Gillotte children s Hospital. In fmticular the changes dw to psoas kngthming over the brim of the pelvis were assessed The study group consisted of 34 subjects (48 sides) that had adeq~pwpaativeandpostop?mdvekinemuticandkinelicdataaMilablefor comparison. In addition, the study group wps compared to a antml gmup of 13 ments (14 sides) who underwent a comparable set of swgeries with the aception that ?o _ surgery was performed. Each of the patim& in both gmops underwent molhple other pmcedorcs under the same me&&. The Vioon Clinical Manager wasuscdtopmcesstidata ‘Ihe prrapaative kinematic status of the study and control groups w slightly different consistmt titttthcpmapwiwdccisioo-makingregdK8ng psas lcngthexdag. ‘f&peak (229 and minimum (139 anterior pelvic tilt was ioawaed in thestudygmupmmpsrsdtonamalbutnotintheconhds(n~nluespel3o and 1 lo mapeztlvely). Hip motion was skewed toward flexion in both gmops but to agmaterextmtinthcstudygrcup. Tbarwasiwmasrdpeakhipfkxi~~inboth gmops (43” vs 420) at initial contact (ncrmai 35”) and duxascd peak hip extension (1o”vs l”fkxion)inpwwing(normalPextm.5ion). Postqxzatively, in UK study gmop, all of these valuee significantl improved toward normal -tin8 an impmvemcnt in their crouch gait pattan. -!hUE?, ccmeapmding preopntive &v&ions in the$ody groap b&ding M inaeased peak hip extensor mnaeat (0.82 Nmikg) whxh occorred later in the gait cycle (13%) than normal (0.48 Nm& 8 4%). The hip moment cnwmw pointfmn~~tofl~w~~~~~~~4l%of the ‘t cyck @rmal = 24%). ‘lbe peak hip fkxor moment ~0s similar1 daxeaxd (O.SGmn;s) and atlayed (56%) ccmpared to norm& (l.aSNmllrg 0 $246). f’ost+ratively, all of thee values wae significantly improved io both groups but moresointbestodygmup. Jnadditkm,tbetotaIextenaormommtandtaalflexor moment were improved with _ surgery. Tlle.v&ttalplaoepwaealaoalmamal prropaatively in both the control and shady gmups. Ihe power Baaption and absmp&m wem diminished in bpth upscomparedtonoimah. h@paatively,tkeHIgateratioapeakwas s1gnlz”caatly dcarar+d in t&e study group (0.12 to 0.05 J ) implying less hip flexor donunamz Ihe H2 absorption peak bwcawd (0.?z to 0.05 J/kg), but ~_~~~~Y. the H3 hi p fl exoI power genera& was not diminished These patientswere found !o have statisticallyincmascd walking velocity @ldi-OXygeo~sndOXygLYtCOStrrvcalingovcnll qnwematt in the&walking timction with surgical intavention. This sudy shows ~slrrgicPlintaveationincl~psoarlengtbeningava~brimofthepelvis significantlyimproves hip kiwnatks and kineticsin nearly alI aspects without sacrificinghip tlexor power guwaticm.
61