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O016 Peak lengthening velocity differs between fixed versus dynamic equines deformity in children with cerebral palsy
Abstracts of the 17th Annual Meeting of ESMAC, Oral Presentations / Gait & Posture 28S (2008) S1–S48 of learning during the session, with an improvement in producing PR and PT simultaneously over time. Discussion: The results suggest that every subject has their own pattern of coordination. In assessing the rate of learning the trend lines indicate that the majority of subjects show limited improvement in a short space of time and maintain a variable pattern of coordination throughout testing, except for subject 4 who demonstrated improvement. As the results show a general lack of improvement during testing, familiarisation before testing one’s performance would not increase their level of core control they already possess. Further investigation will assess the period of time needed to provide an increase in performance level, and to assess the coordination of PR and PT for a larger population to understand how others adapt to the game. In patients with CP focus will be on how a person with reduced core control responds to training of coordination between PR and PT, and the pattern of learning patients produce in response to training.
be a compensation for leg length discrepancy) and decreased arch height (which corresponds to the planus foot position seen clinically). Increased hindfoot dorsiflexion as well as hindfoot external rotation were seen dynamically. Although the clinical examination showed a tendency to a neutral weight-bearing foot position in post operative subjects (3 of 4), this was not shown in the foot model results where the frequency of abnormalities was similar for both pre and post-surgical subjects. There was no difference in the frequency of abnormalities in type I subjects compared with the more severely involved subjects. Kinematic abnormalities (number of subjects) Static
Dynamic
Increased hindfoot dorsiflexion (6) Decreased arch height (5) Increased forefoot adduction (3) Increased forefoot abduction (3)
Increased hindfoot external rotation (5) Increased maximum hindfoot dorsiflexion in stance (3) Increased hindfoot eversion (3) Decreased maximum forefoot dorsiflexion in stance (3)
References [1] Gage JR, Novacheck TF. J Ped Orthop B 2001; 10: 265−74. [2] Graham HK et al. J Bone Joint Surg Br 2005; 87: 548−55. [3] Barton GJ et al. Gait and Posture 2006; 24: 101−2.
O015 Foot kinematics and clinical examination of the unaffected foot in hemiplegic cerebral palsy J. Bates, J. Stebbins, T. Theologis. Oxford Gait Laboratory, Nuffield Orthopaedic Centre, UK Summary: Abnormalities are seen on the unaffected foot of children with hemiplegic cerebral palsy (CP) in the multi-segment foot model data (Oxford Foot Model [1]) and clinical examination. Conclusions: Foot kinematics and the clinical description of foot position of children with hemiplegic CP show abnormalities on the unaffected side. This confirms the clinical impression that the unaffected side has kinematic and clinical abnormalities. Surgery on the affected foot and severity of involvement do not appear to influence the frequency of abnormalities, but future work should explore this further. Introduction: Anecdotally, children with hemiplegic CP sometimes exhibit abnormalities on their unaffected foot. Multisegment foot kinematics were collected bilaterally along with a standardised clinical examination to objectively quantify any abnormalities. Patients/Materials and Methods: The foot model kinematics and clinical examination data of 10 children with hemiplegic CP (mean age 12.3 years, range 8−17 years; 6 male, 4 female; 7 right side and 3 left side affected) were analysed. 6 of the subjects had not had surgery, 4 had foot surgery to their affected side. The subjects tended to be mildly affected (6 type I, 1 type II, 1 type III, 2 type IV, according to Winters’ classification [2]). Static and dynamic foot kinematics were compared to the gait laboratory’s normal child database and any deviation greater than 1 standard deviation from the normal mean was included in the results. Results: The clinical examination demonstrated a tendency towards a planovalgus foot position in weight bearing and a neutral foot position in non weight-bearing. The foot model showed a variety of abnormalities. The most common abnormalities in the static condition were increased hindfoot dorsiflexion (which may
S11
Discussion: The unaffected foot in hemiplegic CP tends to display some abnormalities both in static and dynamic conditions. Severity of involvement and surgery on the affected foot do not affect the frequency of abnormalities on the unaffected side. References [1] Stebbins et al. Gait & Posture; 23(4): 401−10. 2006. [2] Winters TF. J Bone Joint Surg; 69(3): 437−44. 1987.
O016 Peak lengthening velocity differs between fixed versus dynamic equines deformity in children with cerebral palsy ˇ M. Svehl´ ık1 , E.B. Zwick2 , G. Steinwender2 , V. Saraph2 , F. Schneider2 , C. Maizen2 , T. Kraus2 , W. Linhart2 . 1 Department of Children and Adult Orthopaedics, 2nd Medical School, Charles University Prague, Czech Republic; 2 Paediatric Orthopaedic Unit, Department of Paediatric Surgery, University of Graz, Austria Summary: This study used gait analysis and musculoskeletal modelling to evaluate differences between dynamic muscle tightness (DEQ) and fixed contracture (FEQ) of the triceps surae in children with cerebral palsy. Conclusions: Peak lengthening velocity was lower among FEQ group and might be a discriminating factor between FEQ versus DEQ. This parameter could support a challenge in clinical decision-making in equines gait. Introduction: Distinguishing between fixed and dynamic contracture is key-point in decision making. Clinical examination is limited by its static nature and might be invalid if performed in the awake state. Examination under general anaesthesia is an accepted way to differentiate between DEQ and FEQ. Patients/Materials and Methods: All together twenty-three children (31 limbs) with spastic cerebral palsy (8 diplegic and 15 hemiplegic) and equines gait pattern were. According to an examination under anaesthesia 12 limbs were evaluated as FEQ and 19 had DEQ. Gait analysis was performed and Mobile Gait Lab [1] software (Technical University, Duisburg, Germany) was used to compute muscle length and velocities. The specification
S12
Abstracts of the 17th Annual Meeting of ESMAC, Oral Presentations / Gait & Posture 28S (2008) S1–S48
of the lower extremity architecture was based on the origin and insertion coordinate data compiled by Delp [2]. Non-parametric Mann-Whitney U test was used for comparison between DEQ and FEQ.
of triceps muscle velocities MGAC (p = 0.056), LGAC (p = 0.123), SOL (p = 0.031). Discussion: Our results indicate that all three triceps surae muscle achieve significantly lower peak lengthening velocity in FEQ group. Peak lengthening velocity occurred in early swing phase during dorsiflexion of the ankle. Decreased peak lengthening velocity might be result of increased stiffness and/or change in architecture of triceps surae muscle. Spastic muscle cells have shorter resting sarcomere length and develop passive tension on significantly shorter sarcomere length compared to healthy individual [3]. Muscle velocity might help us with defferenciation between DEQ and FEQ without the need of general anaesthesia. References [1] Stolz, M. Modellbildung, Simulation und Analyse der menschlichen Beinbewegung zur Vorbereitung chirurgischer Eingriffe [Diplomarbeit]. Graz: Technische Universit¨at. 110pp, 2002. [2] Delp, SL, Loan, JP, Hoy, MG et al. An interactive graphics-based model of the lower extremity to study orthopaedic surgical procedures. IEEE TransBiomedEng, 37: 757–767, 1990. [3] Friden, J, Lieber, RL. Spastic muscle cells are shorter and stiffer than normal cells. Muscle Nerve, 27: 157–164, 2003.
O017 Biomechanical analysis of lower limbs for children with cerebral palsy: gait analysis and musculo-skeletal modelling A. Assi1 , I. Ghanem2 , W. Skalli3 . 1 LBM, ENSAM Paris/SESOBEL Beirut; 2 HDF, Hotel Dieu de France of Beirut Hospital, France
Figure 1. Results: There was no difference in ankle kinematics and only maximal ankle power over the second half of the stance phase was higher in DEQ group (p = 0.012). Maximal lengthening velocity of triceps surae muscle was significantly higher in DEQ group (Fig. 1), medial MGAC (p = 0.019) and lateral gastrocnemius LGAC (p = 0.039), soleus SOL (p = 0.006) and occurred in the early swing phase. FEQ group is operating over a narrower interval
Summary: A new protocol of diagnosis for children with CP is described, based on gait analysis and specific patients’ 3D lower limbs reconstruction of bones and muscles. Conclusions: Feasibility of skeletal malalignment and muscular deformities quantification is assessed in 3D and in standing position. The specific subject 3D approach, combining gait analysis and musculo-skeletal reconstruction, provides more accurate data for clinicians and allows a better treatment decision making. Introduction: Orthopaedic clinical decision-making for children with CP should be based on a global approach regrouping information on gait patterns, skeletal malalignment and muscletendon unit deformities. Patients/Materials and Methods: Gait analysis databases, using Plug in Gait® protocol, were collected for 56 healthy children and 45 patients with CP, between 5 and 15 years old (Vicon® devices, with dynamic EMG). 17 healthy subjects performed the exam twice for repeatability study [1]. Frontal and lateral X-Rays in standing position using the EOS® low dose biplanar X-Rays system (Biospace Med) of 12 children (6 CP and 6 non CP), between 5 and 15 years, were obtained [2]. Individual 3D reconstructions of lower limbs were realized by selecting points and contours on both X-Rays. Clinical axes and angles were computed on these reconstructions. Matching 3D subject specific bones in gait analysis frames was proposed. MRI acquisitions were done for 3 healthy children (9, 11 and 14 years old) and 1 CP patient (diplegic, 8 years old). Horizontal slices in T1 were provided from iliac spine to foot. A specific technique [3] was used to obtain specific subject 3D reconstructions in lying position of 19 muscles at left and right lower limbs by selecting contours on few slices. Volumes, Physiological Cross Sectional Areas (PCSA) and Lengths of muscles were calculated. 3D muscle
be a compensation for leg length discrepancy) and decreased arch height (which corresponds to the planus foot position seen clinically). Increased hindfoot dorsiflexion as well as hindfoot external rotation were seen dynamically. Although the clinical examination showed a tendency to a neutral weight-bearing foot position in post operative subjects (3 of 4), this was not shown in the foot model results where the frequency of abnormalities was similar for both pre and post-surgical subjects. There was no difference in the frequency of abnormalities in type I subjects compared with the more severely involved subjects. Kinematic abnormalities (number of subjects) Static
Dynamic
Increased hindfoot dorsiflexion (6) Decreased arch height (5) Increased forefoot adduction (3) Increased forefoot abduction (3)
Increased hindfoot external rotation (5) Increased maximum hindfoot dorsiflexion in stance (3) Increased hindfoot eversion (3) Decreased maximum forefoot dorsiflexion in stance (3)
References [1] Gage JR, Novacheck TF. J Ped Orthop B 2001; 10: 265−74. [2] Graham HK et al. J Bone Joint Surg Br 2005; 87: 548−55. [3] Barton GJ et al. Gait and Posture 2006; 24: 101−2.
O015 Foot kinematics and clinical examination of the unaffected foot in hemiplegic cerebral palsy J. Bates, J. Stebbins, T. Theologis. Oxford Gait Laboratory, Nuffield Orthopaedic Centre, UK Summary: Abnormalities are seen on the unaffected foot of children with hemiplegic cerebral palsy (CP) in the multi-segment foot model data (Oxford Foot Model [1]) and clinical examination. Conclusions: Foot kinematics and the clinical description of foot position of children with hemiplegic CP show abnormalities on the unaffected side. This confirms the clinical impression that the unaffected side has kinematic and clinical abnormalities. Surgery on the affected foot and severity of involvement do not appear to influence the frequency of abnormalities, but future work should explore this further. Introduction: Anecdotally, children with hemiplegic CP sometimes exhibit abnormalities on their unaffected foot. Multisegment foot kinematics were collected bilaterally along with a standardised clinical examination to objectively quantify any abnormalities. Patients/Materials and Methods: The foot model kinematics and clinical examination data of 10 children with hemiplegic CP (mean age 12.3 years, range 8−17 years; 6 male, 4 female; 7 right side and 3 left side affected) were analysed. 6 of the subjects had not had surgery, 4 had foot surgery to their affected side. The subjects tended to be mildly affected (6 type I, 1 type II, 1 type III, 2 type IV, according to Winters’ classification [2]). Static and dynamic foot kinematics were compared to the gait laboratory’s normal child database and any deviation greater than 1 standard deviation from the normal mean was included in the results. Results: The clinical examination demonstrated a tendency towards a planovalgus foot position in weight bearing and a neutral foot position in non weight-bearing. The foot model showed a variety of abnormalities. The most common abnormalities in the static condition were increased hindfoot dorsiflexion (which may
S11
Discussion: The unaffected foot in hemiplegic CP tends to display some abnormalities both in static and dynamic conditions. Severity of involvement and surgery on the affected foot do not affect the frequency of abnormalities on the unaffected side. References [1] Stebbins et al. Gait & Posture; 23(4): 401−10. 2006. [2] Winters TF. J Bone Joint Surg; 69(3): 437−44. 1987.
O016 Peak lengthening velocity differs between fixed versus dynamic equines deformity in children with cerebral palsy ˇ M. Svehl´ ık1 , E.B. Zwick2 , G. Steinwender2 , V. Saraph2 , F. Schneider2 , C. Maizen2 , T. Kraus2 , W. Linhart2 . 1 Department of Children and Adult Orthopaedics, 2nd Medical School, Charles University Prague, Czech Republic; 2 Paediatric Orthopaedic Unit, Department of Paediatric Surgery, University of Graz, Austria Summary: This study used gait analysis and musculoskeletal modelling to evaluate differences between dynamic muscle tightness (DEQ) and fixed contracture (FEQ) of the triceps surae in children with cerebral palsy. Conclusions: Peak lengthening velocity was lower among FEQ group and might be a discriminating factor between FEQ versus DEQ. This parameter could support a challenge in clinical decision-making in equines gait. Introduction: Distinguishing between fixed and dynamic contracture is key-point in decision making. Clinical examination is limited by its static nature and might be invalid if performed in the awake state. Examination under general anaesthesia is an accepted way to differentiate between DEQ and FEQ. Patients/Materials and Methods: All together twenty-three children (31 limbs) with spastic cerebral palsy (8 diplegic and 15 hemiplegic) and equines gait pattern were. According to an examination under anaesthesia 12 limbs were evaluated as FEQ and 19 had DEQ. Gait analysis was performed and Mobile Gait Lab [1] software (Technical University, Duisburg, Germany) was used to compute muscle length and velocities. The specification
S12
Abstracts of the 17th Annual Meeting of ESMAC, Oral Presentations / Gait & Posture 28S (2008) S1–S48
of the lower extremity architecture was based on the origin and insertion coordinate data compiled by Delp [2]. Non-parametric Mann-Whitney U test was used for comparison between DEQ and FEQ.
of triceps muscle velocities MGAC (p = 0.056), LGAC (p = 0.123), SOL (p = 0.031). Discussion: Our results indicate that all three triceps surae muscle achieve significantly lower peak lengthening velocity in FEQ group. Peak lengthening velocity occurred in early swing phase during dorsiflexion of the ankle. Decreased peak lengthening velocity might be result of increased stiffness and/or change in architecture of triceps surae muscle. Spastic muscle cells have shorter resting sarcomere length and develop passive tension on significantly shorter sarcomere length compared to healthy individual [3]. Muscle velocity might help us with defferenciation between DEQ and FEQ without the need of general anaesthesia. References [1] Stolz, M. Modellbildung, Simulation und Analyse der menschlichen Beinbewegung zur Vorbereitung chirurgischer Eingriffe [Diplomarbeit]. Graz: Technische Universit¨at. 110pp, 2002. [2] Delp, SL, Loan, JP, Hoy, MG et al. An interactive graphics-based model of the lower extremity to study orthopaedic surgical procedures. IEEE TransBiomedEng, 37: 757–767, 1990. [3] Friden, J, Lieber, RL. Spastic muscle cells are shorter and stiffer than normal cells. Muscle Nerve, 27: 157–164, 2003.
O017 Biomechanical analysis of lower limbs for children with cerebral palsy: gait analysis and musculo-skeletal modelling A. Assi1 , I. Ghanem2 , W. Skalli3 . 1 LBM, ENSAM Paris/SESOBEL Beirut; 2 HDF, Hotel Dieu de France of Beirut Hospital, France
Figure 1. Results: There was no difference in ankle kinematics and only maximal ankle power over the second half of the stance phase was higher in DEQ group (p = 0.012). Maximal lengthening velocity of triceps surae muscle was significantly higher in DEQ group (Fig. 1), medial MGAC (p = 0.019) and lateral gastrocnemius LGAC (p = 0.039), soleus SOL (p = 0.006) and occurred in the early swing phase. FEQ group is operating over a narrower interval
Summary: A new protocol of diagnosis for children with CP is described, based on gait analysis and specific patients’ 3D lower limbs reconstruction of bones and muscles. Conclusions: Feasibility of skeletal malalignment and muscular deformities quantification is assessed in 3D and in standing position. The specific subject 3D approach, combining gait analysis and musculo-skeletal reconstruction, provides more accurate data for clinicians and allows a better treatment decision making. Introduction: Orthopaedic clinical decision-making for children with CP should be based on a global approach regrouping information on gait patterns, skeletal malalignment and muscletendon unit deformities. Patients/Materials and Methods: Gait analysis databases, using Plug in Gait® protocol, were collected for 56 healthy children and 45 patients with CP, between 5 and 15 years old (Vicon® devices, with dynamic EMG). 17 healthy subjects performed the exam twice for repeatability study [1]. Frontal and lateral X-Rays in standing position using the EOS® low dose biplanar X-Rays system (Biospace Med) of 12 children (6 CP and 6 non CP), between 5 and 15 years, were obtained [2]. Individual 3D reconstructions of lower limbs were realized by selecting points and contours on both X-Rays. Clinical axes and angles were computed on these reconstructions. Matching 3D subject specific bones in gait analysis frames was proposed. MRI acquisitions were done for 3 healthy children (9, 11 and 14 years old) and 1 CP patient (diplegic, 8 years old). Horizontal slices in T1 were provided from iliac spine to foot. A specific technique [3] was used to obtain specific subject 3D reconstructions in lying position of 19 muscles at left and right lower limbs by selecting contours on few slices. Volumes, Physiological Cross Sectional Areas (PCSA) and Lengths of muscles were calculated. 3D muscle