Impact of gait analysis on pathology identification and surgical recommendations in children with spina bifida.

BACKGROUND: Gait analysis provides quantitative data that can be used to supplement standard clinical evaluation in identifying and understanding gait problems. It has been established that gait analysis changes treatment decision making for children with cerebral palsy, but this has not yet been studied in other diagnoses such as spina bifida. RESEARCH QUESTION: To determine the effects of gait analysis data on pathology identification and surgical recommendations in children with spina bifida. METHODS: Two pediatric orthopaedic surgeons and two therapists with >10 years of experience in gait analysis reviewed clinical, video, and gait analysis data from 43 ambulatory children with spina bifida (25 male; mean age 11.7 years, SD 3.8; 25 sacral, 18 lumbar). Primary gait pathologies were identified by each assessor both before and after consideration of the gait analysis data. Surgical recommendations were also recorded by the surgeons before and after consideration of the gait analysis data. Frequencies of pathology and surgery identification with and without gait analysis were compared using Fisher's exact test, and percent change in pathology and surgery identification was calculated. RESULTS: Pathology identification often changed for common gait problems including crouch (28% of cases), tibial rotation (35%), pes valgus (18%), excessive hip flexion (70%), and abnormal femur rotation (75%). Recognition of excessive hip flexion and abnormal femur rotation increased significantly after consideration of gait analysis data (p < 0.05). Surgical recommendations also frequently changed for the most common surgeries including tibial derotation osteotomy (30%), antero-lateral release (22%), plantar fascia release (33%), knee capsulotomy (25%), 1st metatarsal osteotomy (60%), and femoral derotation osteotomy (89%). At the patient level, consideration of gait analysis data altered surgical recommendations for 44% of patients. SIGNIFICANCE: Since gait analysis data often changes pathology identification and surgical recommendations, treatment decision making may be improved by including gait analysis in the patient care process.

Comparison of 2 Orthotic Approaches in Children With Cerebral Palsy.

PURPOSE: To compare dynamic ankle-foot orthoses (DAFOs) and adjustable dynamic response (ADR) ankle-foot orthoses (AFOs) in children with cerebral palsy. METHODS: A total of 10 children with cerebral palsy (4-12 years; 6 at Gross Motor Function Classification System level I, 4 at Gross Motor Function Classification System level III) and crouch and/or equinus gait wore DAFOs and ADR-AFOs, each for 4 weeks, in randomized order. Laboratory-based gait analysis, walking activity monitor, and parent-reported questionnaire outcomes were compared among braces and barefoot conditions. RESULTS: Children demonstrated better stride length (11-12 cm), hip extension (2°-4°), and swing-phase dorsiflexion (9°-17°) in both braces versus barefoot. Push-off power (0.3 W/kg) and knee extension (5°) were better in ADR-AFOs than in DAFOs. Parent satisfaction and walking activity (742 steps per day, 43 minutes per day) were higher for DAFOs. CONCLUSIONS: ADR-AFOs produce better knee extension and push-off power; DAFOs produce more normal ankle motion, greater parent satisfaction, and walking activity. Both braces provide improvements over barefoot.

Outcomes of lower extremity orthopedic surgery in ambulatory children with cerebral palsy with and without gait analysis: results of a randomized controlled trial.

This study examined the impact of gait analysis on surgical outcomes in ambulatory children with cerebral palsy (CP) through a randomized controlled trial. 156 children with CP (94 male; age 10.2 ± 3.7 years) underwent gait analysis and were randomized to two groups: Gait Report group (N = 83), where the referring surgeon received the patient's gait analysis report, and Control group (N = 73), where the surgeon did not receive the gait report. Outcomes were assessed pre- and 1.3 ± 0.5 years post-operatively. An intent-to-treat analysis compared outcomes between the two groups. Outcome measures included the Gillette Functional Activity Questionnaire (FAQ), Gait Deviation Index (GDI), oxygen cost, gross motor function measure, Child Health Questionnaire (CHQ), Pediatric Outcomes Data Collection Instrument (PODCI), and Pediatric Evaluation and Disability Inventory. The outcomes that differed significantly between groups were change in health from the CHQ, which was rated as much better for 56% (46/82) of children in the Gait Report group compared with 38% (28/73) in the Control group (p = 0.04), and upper extremity physical function from the PODCI. Gait outcomes (FAQ and GDI) improved more when over half of the recommendations for a patient were followed or the recommended extent of surgery (none, single, or multi-level) was done (p ≤ 0.04). On average, however, only 42% of the recommendations were followed in the Gait Report group, compared with 35% in the Control group (p = 0.23). This is much less than the >85% reported in previous studies and may account for the lack of differences between groups for some of the outcome measures.

Causes of intoeing gait in children with cerebral palsy.

BACKGROUND: Intoeing is a frequent gait problem in children with cerebral palsy. It is essential to determine the cause(s) of intoeing when surgical intervention is being planned. The purpose of this study was to evaluate the prevalence of various causes of intoeing in children with cerebral palsy and to determine whether the causes differ between children with bilateral and those with unilateral involvement. METHODS: The cause of intoeing gait was examined retrospectively, with use of gait analysis, in 412 children with cerebral palsy (587 involved sides). The causes were evaluated separately for the children with bilateral involvement (diplegia or quadriplegia) and those with hemiplegia. RESULTS: Overall, the most common causes of intoeing were internal hip rotation (322 of 587 sides) and internal tibial torsion (296 of 587 sides). Pes varus contributed to intoeing of thirty-five of the eighty-two involved limbs of the patients with hemiplegia and of forty-two of the 505 limbs of the patients with diplegia or quadriplegia. Multiple causes of intoeing were noted in 215 of the 587 involved limbs, including 176 of the 505 limbs of the patients with bilateral involvement and thirty-nine of the eighty-two involved limbs of the patients with hemiplegia. The most common causes of intoeing in the subjects with bilateral involvement were internal hip rotation (288 of 505), internal tibial torsion (261 of 505), and internal pelvic rotation (ninety-two of 505). The most common causes in the hemiplegic children were internal tibial torsion (thirty-five of eighty-two), pes varus (thirty-five of eighty-two), internal hip rotation (thirty-four of eighty-two), and metatarsus adductus (twenty of eighty-two). CONCLUSIONS: More than one-third of children with cerebral palsy have multiple causes of intoeing. Pes varus commonly contributes to intoeing by children with hemiplegic cerebral palsy but rarely contributes to intoeing by those with diplegia or quadriplegia. These findings should be carefully considered prior to surgical correction of the intoeing gait of these patients.

Reliability and validity of visual assessments of gait using a modified physician rating scale for crouch and foot contact.

This study evaluates the visual assessment of gait using portions of the Physicians' Rating Scale (PRS). Thirty children with pathologic gait were evaluated "live" and using full- and slow-speed video. Interobserver reliability (weighted kappa) was 0.57 to 0.74 for foot contact, 0.69 to 0.71 for crouch, 0.30 to 0.40 for hip flexion, 0.57 to 0.65 for knee flexion, and 0.42 to 0.52 for dorsiflexion in stance. Intraobserver reliability (comparing the three conditions) was 0.50 to 0.78 for foot contact, 0.71 to 0.80 for crouch, 0.26 to 0.44 for hip flexion, 0.60 to 0.86 for knee flexion, and 0.39 to 0.61 for dorsiflexion. Observers were correct only 12% to 32% of the time when reporting less than 0 degrees of dorsiflexion and 0% to 29% of the time when reporting more than 20 degrees of hip flexion due to overestimation of hip flexion and underestimation of ankle dorsiflexion. These errors could lead some clinicians to presume the presence of contractures that do not actually exist. Visual assessment using the PRS does not appear to accurately measure what it is most commonly used to assess: ankle position in stance.