Investigating the association between self-reported physical function, temporo-spatial parameters, walking kinematics and community-based ambulatory activity: Analysis of post-operative hip preservation patients.

INTRODUCTION: Wearable sensors provide the ability to assess ambulatory activity in the community after hip preservation surgery (HPS). In combination with gait analysis and patient reported outcomes, more perspective on post-operative function is gained. The purpose of this study was to assess the relationship between self-reported function/activity, temporo-spatial parameters and walking kinematics to objectively measured ambulatory activity. METHODS: Forty-nine participants (38 Females; age range 16-38 years) who were five years or more post-surgery and the following diagnoses were included: Acetabular Dysplasia (n=34), Femoroacetabular Impingement (n=12) and Legg-Calvé Perthes disease (n=3). Participants underwent 3D gait analysis and gait deviations were quantified using the Gait Deviation Index (GDI) and Gait Profile Score (GPS). Temporo-spatial parameters were also calculated. Self-reported pain/function and activity level were assessed via the Harris Hip Score (HHS) and UCLA Activity Scale (UCLA). Participants wore a StepWatch Activity Monitor in their community and the Intensity/Duration of ambulatory bouts were analyzed. Spearman correlation coefficients were run to assess the following relationships: in-lab walking measures, self-reported function/activity vs.community ambulatory activity. RESULTS: There were no statistically significant correlations between HHS, UCLA or temporospatial parameters with ambulatory activity (p>0.05). Worsening gait deviations (GDI/GPS scores) correlated with daily total ambulatory time (ρ=0.284/-0.284, p<0.05), time spent in Short duration ambulatory bouts (ρ=-0.321/0.321, p<0.05) and the amount of time in Long duration ambulatory bouts (ρ=0.366/-0.366, p<0.05). The amount of time spent in Easy intensity/Short duration and Easy intensity/Long duration ambulatory bouts did have a weak correlation with the GDI and GPS (p<0.05). CONCLUSIONS: In HPS patients after long-term follow up, ambulatory activity in the community did not correlate with patient reported outcomes but there was a weak correlation with the presence of gait deviations. Incorporating wearable sensors to assess community ambulatory bout intensity/duration, provides additional quantifiable measures into the overall function of patients following HPS.

Effect of Body Mass Index on Pedobarographic and Patient-Reported Outcome Measures in Adolescent Flexible Flat Feet.

BACKGROUND: Although adolescent flexible flatfoot deformity (FFD) is common, little is known regarding the effect of weight on associated symptomatology. This study uses pedobarography and patient-reported outcome measures (PROs) to determine if overweight adolescents with FFD have more severe alterations in dynamic plantar pressures than normal body mass index percentiles (wnBMI) with FFD and if such alterations correlate with pain and activity. METHODS: A retrospective review of patients aged 10 to 18 years with nonsyndromic symptomatic FFD was performed. Overweight (BMI percentile ≥ 85%) patients were compared with wnBMI patients with regard to dynamic plantar pressure measures and PRO scores. Pedobarographic data were subdivided into regions: medial/lateral hindfoot and midfoot, and first, second, and third to fifth metatarsals. Plantar pressure variables were normalized to account for differences in foot size, body weight, and walking speed. Contact area (CA%), maximum force by body weight (MF%), and contact time as a percentage of the rollover process (CT%) were calculated. Two foot-specific PROs were assessed, including the Foot and Ankle Outcome Score and the Oxford Ankle Foot Measure for Children. RESULTS: Of the 48 adolescents studied, 27 (56%) were overweight and 21 (44%) were wnBMI. After normalization of the data, overweight patients had significantly greater medial midfoot MF%, whereas CT% was increased across the medial and lateral midfoot and hindfoot regions. Correlations showed positive trends: as BMI percentile increases, so will CA and MF in the medial midfoot, as well as CT in the medial and lateral midfoot and hindfoot. Significant differences were seen between groups, with the overweight group reporting lower sports and recreation subscores than the wnBMI group. No significant differences were seen in the pain and disability subscores. CONCLUSIONS: Although overweight adolescents with FFD exhibit greater forces and more time spent during the rollover process in the medial midfoot than normal-weight patients, they did not report worse pain or disability associated with their flat foot deformity. LEVEL OF EVIDENCE: Therapeutic level 3.

Long-term Outcomes of Surgically Treated Congenital Dislocation of the Knee.

BACKGROUND: Congenital dislocation of the knee (CDK) may be idiopathic or associated with another condition, such as Larsen syndrome or arthrogryposis. Surgical reduction of type-3 dislocation may require quadricepsplasty (QP) or femoral diaphyseal shortening (FS). Because it is unknown which treatment is more effective, we evaluated long-term outcomes using patient-reported questionnaires and gait analysis, comparing results by surgery type and underlying diagnosis. METHODS: Twelve patients (mean age, 19 mo) were treated surgically for CDK from 1985 to 2015 and studied 9 to 30 years postoperatively. Three participants had idiopathic CDK, 5 had Larsen syndrome, and 4 had arthrogryposis. Eleven knees underwent QP and 7 underwent FS. Participants were evaluated in our movement science laboratory and completed patient-reported outcome questionnaires. Data were compared with healthy, age-matched control values at the same visit. RESULTS: Surgically treated knees had less flexion during swing (P<0.01), less overall motion (P<0.01), greater coronal instability (P<0.04), and slower gait (P<0.01) compared with controls. QP knees had more instability in midstance (P=0.03) and less flexion during gait compared with FS knees, less sagittal power generation than controls (P<0.01), and trended toward lower scores on Knee Injury and Osteoarthritis Outcome and Lysholm Knee Questionnaires than FS patients did. The idiopathic group had the gait most similar to that of controls, followed by the Larsen syndrome group and then the arthrogryposis group. The idiopathic group also had a better UCLA Activity Score (P=0.03) than the arthrogryposis group did. CONCLUSIONS: Surgical treatment of type-3 CDK will not likely restore normal knee function, suggesting teratologic joint abnormality. In this small series, FS produced better gait mechanics and patient-reported outcomes compared with QP. Not surprisingly, patients with idiopathic CDK had better outcomes than those with a syndromic diagnosis, likely related to having only a single joint affected. LEVEL OF EVIDENCE: Level III.

Investigating pelvic drop gait abnormality in adolescent hip pathology patients.

BACKGROUND: Trendelenburg gait describes contralateral pelvic drop during single leg stance (SLS) with occasional lateral trunk lean compensation over the stance limb. However, quantitative research on 'uncompensated Trendelenburg' gait (pelvic drop independent of lateral trunk lean) remains sparse among populations that commonly utilize this gait pattern, such as adolescent hip pathology patients. RESEARCH QUESTION: How prevalent is uncompensated Trendelenburg among various adolescent hip pathologies and how is it related to hip load, hip abduction strength, and self-reported hip pain? METHODS: Gait, strength, and pain data were collected among 152 pre-operative patients clinically diagnosed with acetabular hip dysplasia, femoroacetabular impingement, Legg-Calvé-Perthes, or slipped capital femoral epiphysis (SCFE). Patients with ≥ 5.4° of dynamic pelvic drop in SLS were divided into a 'pelvic drop' group and screened to exclude those with excessive ipsilateral trunk lean. They were then compared to the 'stable pelvis' patients using a Mann-Whitney test. RESULTS: Dysplasia patients represented the highest proportion of the pelvic drop group (46%). The pelvic drop group showed a significant increase in self-reported hip pain (p = 0.011), maximum hip abductor moment (p = 0.002), and peak coronal power absorption at the affected hip during SLS loading response, (p < 0.001) while showing no difference in abduction strength (p = 0.381). SIGNIFICANCE: Uncompensated Trendelenburg gait may lead to increased loading of the affected hip in adolescent hip pathology patients. Disadvantageous hip biomechanics can create increased abductor muscle demand among these pathological populations, with dysplasia patients showing the highest prevalence. Maximal abduction strength did not correlate with pelvic drop. Future work should aim to identify and quantify causal factors. Increased coronal hip power absorption during weight acceptance warrants clinical attention, as there may be a detrimental, over-reliance on passive hip structures to support load among a population that that is already predisposed to hip osteoarthritis.

Normative dataset selection affects gait profile scores of children with cerebral palsy.

INTRODUCTION: The Gait Profile Score (GPS) requires a comparative dataset, to identify altered mechanics in persons with a gait abnormality. This gait index has been shown to be useful for identifying gait pathology prior to the assessment of treatment outcomes. Though studies have shown differences in kinematic normative datasets between different testing sites, there is limited information available on the changes in GPS score based on normative dataset selection. The aim of this study was to quantify the influence of normative reference data from two institutions, on the GPS and Gait Variable Scores (GVS), calculated on the same group of patients with Cerebral Palsy. METHODS: Seventy patients (Avg. age: 12.1 ± 2.9) diagnosed with CP underwent gait analysis during walking at a self-selected speed at Scottish Rite for Children (SRC). GPS and GVS scores were determined using normative kinematic data at a self-selected speed from, 83 typically developing children ages 4-17 from Gillette, and the same age range of children from SRC's normative dataset. Average normalized speed was compared between institutions. Signed rank tests were performed on the GPS and GVS scores using each institution's dataset. Spearman's correlations between scores using SRC and Gillette were determined within GMFCS level. RESULTS: Normalized speed was comparable between each institution's datasets. Within each GMFCS level, significant differences when using SRC vs. Gillette were found in most scores (p < 0.05). Scores were moderately to strongly correlated within each GMFCS level (range ρ = 0.448-0.998). CONCLUSIONS: Significant statistical differences were found in GPS and GVS scores but were within the range of previously reported variation across multiple sites. Caution and consideration may need to be taken when reporting GPS and GVS scores that are calculated utilizing different normative datasets as these scores may not be equivalent.

Disparity in Built Environment and Its Impacts on Youths' Physical Activity Behaviors During COVID-19 Pandemic Restrictions.

OBJECTIVES: Guided by the social ecological model, this study aimed to examine the relations of built environments (i.e., walking/cycling infrastructure, recreation facilities, neighborhood safety/crime), youth's transition abilities, and changes of youth's physical activity (PA) and play behaviors due to COVID-19-based restrictions. Ethnic and socioeconomic status (SES) disparities were also examined on studies variables during the COVID-19 restrictions. METHOD: A cross-sectional research design was used to assess an anonymous online survey completed by US parents/guardians. The final sample had 1324 children and adolescents (Meanage = 9.75; SD = 3.95; 51.3% girls), and 35.5% the families were of upper socioeconomic class (income > $150,000). Parents reported the perceived built environment and neighborhood safety, child's PA and play behaviors during COVID-19 pandemic shelter-in-place restrictions. RESULTS: Youths who had access to safe built environment were more active and played more outdoor/indoor (p < .01). It was found playing behavior in yard and neighborhood were significantly increased, but community-based play behavior was significantly reduced during COVID-19 restrictions. The SEM analysis (χ2/df = 236.04/54; CFI = .966) supported indirect and direct effects of neighborhood safety on PA changes during COVID-19 restrictions, and the youth's ability to respond to COVID-19 restrictions served as a full mediator. Low-SES and Hispanic minority youth reported significantly less safety to walking or playing in their neighborhoods than their middle-/high-SES non-Hispanic peers (p < .001). Regardless of ethnicity, the magnitude of the reduction of MVPA was significantly higher among low-SES groups than that of the high- and middle-SES groups (p < .001). CONCLUSIONS: These findings demonstrate a need to tailor programs and policies to help high-risk groups (e.g., low SES) stay active, healthy, and resilient during and after the COVID-19 pandemic.

Inclusive community playgrounds benefit typically developing children: An objective analysis of physical activity.

Purpose: Limited research is available on the physical activity levels of children while playing on an inclusive playground, specifically designed to accommodate children with physical disabilities. The aims of this study were to objectively measure ambulatory activity and heart rate (HR) of children during unstructured play on an inclusive community playground. Methods: Typically developing children at least 4 years of age were recruited to play freely upon entering the playground. Participants wore a StepWatch4 Activity Monitor and a Polar V800 Sport Watch. Ambulatory measures included total steps, percentage of recommended steps, total ambulatory time (TAT), bout intensity levels/duration periods. Time spent in HR zones and moderate-to-vigorous physical activity (MVPA) was determined. Results: 95 children (48 males; Avg. age: 7 ± 2 years.) were included in this study. Children played for 31.8 ± 14.7 min., were ambulatory for 25.9 ± 12.0 min., took 1826 ± 824 steps, and accumulated 17 ± 8% of the recommended daily step count. Ambulatory bout intensity was predominantly lower intensity and bout durations varied in length. 99% of the play time was spent at a moderate HR or higher. Significant correlations were found between ambulatory and HR measures (ρ range from 0.23 to 0.99, p < 0.05), and 7-10 yo children spent a significantly higher percentage of TAT at higher intensity ambulation (p < 0.05). Conclusions: Typically developing children can achieve moderate or higher intensity exercise and HR on an inclusive playground. Both typically developing children and those with disabilities, would benefit from a setting where they can interact and participate in parallel play with their peers.

This is a narrative review of the functional evaluation of clubfoot treatment with gait analysis.

Clinicians worldwide have embraced Ponseti's nonoperative approach in the treatment of clubfoot, primarily due to ubiquitous reports of successful outcomes. A crucial component in this measured success, has come from researchers assessing long-term physical function following nonoperative treatment. Gait analysis has been instrumental in objectively evaluating lower extremity kinematics and kinetics while plantar pressures demonstrate the load bearing patterns experienced in the foot. As technology improves, our ability to evaluate function can take place both in the laboratory setting, and in the community. For over 20 years, our institution has been studying the gait patterns of children treated for clubfoot. After adopting the nonoperative approach, we established a prospective research program that has allowed us to study functional outcomes in the very young walker, through growth to adolescents, and finally at skeletal maturity. We have seen over 450 children treated for clubfoot in the Movement Science Lab, for over 1,250 gait assessments over the span of this study. Early results in 105 children (154 feet) treated nonoperatively for clubfoot, showed 56% of children had normal sagittal plane ankle kinematics, however an incidence of 48% of Ponseti feet had increased dorsiflexion in stance phase, leading us to wonder if this was the result of the tenotomy. Intermediate follow up at age 5 years, showed that the incidence of increased dorsiflexion was reduced (24%) and ankle power did not appear to be affected (P>0.05 compared to controls). The research highlighted in this paper presents the application of functional evaluation through growth and the long-term effects of nonoperative treatment on gait and function. This is a review of the functional outcome studies from our experience at Scottish Rite for Children.

Comparison of Outcomes by Reconstructive Strategy in Patients with Prostheses for Proximal Femoral Focal Deficiency.

BACKGROUND: The present study compares prosthetic treatment options for proximal femoral focal deficiency in terms of gait analysis, oxygen consumption, and patient-reported outcomes. METHODS: Twenty-three patients who had been managed with a prosthesis for unilateral proximal femoral focal deficiency underwent gait analysis; this group included 7 patients who had received an equinus prosthesis, 6 who had received a rotationplasty prosthesis, and 10 who had undergone Syme amputation and had received an above-the-knee prosthesis. Cadence parameters, kinematic and kinetic data, and oxygen consumption were measured, and the Gait Deviation Index (GDI) was calculated. Medical records and radiographs were reviewed. The Pediatric Outcomes Data Collection Instrument (PODCI) was completed by the child's parent. RESULTS: Patients underwent gait analysis at a mean age of 11.6 years (range, 4 to 19 years). Proximal femoral focal deficiency classification was not predictive of the chosen treatment. Patients in the rotationplasty group had undergone more procedures than those in the Syme amputation and equinus groups (mean, 3.3, 1.8, and 0.7 procedures, respectively) (p = 0.001). Oxygen cost did not differ between groups; however, all required greater energy expenditure than normal (170%, 144%, and 159%, in the equinus, rotationplasty, and Syme amputation groups, respectively) (p = 0.427). Likewise, hip power, abductor impulse, and GDI did not differ, but all groups had GDI scores >3 standard deviations below normative values. Patients in the equinus group walked faster (97% of normal for age) than those in the rotationplasty (84%) and Syme amputation groups (83%) (p = 0.018), whereas those in the Syme amputation group had superior knee range of motion (55° from the prosthetic knee) than those in the equinus (20°) and rotationplasty groups (15° generated from the ankle) (p = 0.003). There were no differences in terms of the PODCI subscales for pain, sport/physical function, happiness, or global function. Transfer/basic mobility improved with age (r = 0.516, p = 0.017), but no other associations were found between gait variables and PODCI scores. CONCLUSIONS: Rotationplasty provided no patient-reported benefit and no functional benefit in terms of gait parameters or oxygen consumption, despite requiring more surgical procedures compared with other prosthetic options. Patients with an equinus prosthesis walked the fastest, whereas treatment with a Syme amputation and prosthetic knee yielded equivalent gait parameters and oxygen consumption as compared with those for patients using an equinus prosthesis. These findings contradict those of previous reports that rotationplasty provides superior function over other proximal femoral focal deficiency prosthetic treatment options. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Plantar Pressures Following Surgical Release in Children With Clubfoot: Comparison of Posterior Release, Posteromedial Release, and Nonoperative Correction.

BACKGROUND: Functional deficits observed at long-term follow-up in surgically released clubfeet have led to the adoption of a nonoperative approach. Gait results reported at age 5 years found ankle motion was limited in clubfeet treated by posteromedial release (PMR), compared with those that required posterior release (PR) or remained nonoperative. The purpose of this study was to assess plantar pressures in clubfeet that required surgical correction by 5 years of age. METHODS: Pedobarograph data were collected at age 5 years on patients with clubfeet that underwent surgical correction due to residual deformity or recurrence. Plantar pressures were assessed by subdividing the foot into the medial/lateral hindfoot, midfoot, and forefoot regions. Variables included maximum force, contact area%, contact time% (CT%), the hindfoot-forefoot angle, and displacement of the center of pressure line. Surgical feet were divided into those that underwent an isolated PR versus PMR. A group of 72 clubfeet that remained nonoperative were matched by initial severity and used for comparison. RESULTS: Pedobarograph data from 53 patients (72 clubfeet; 25 PR and 47 PMR) showed minimal differences between the PR and PMR feet. Compared with the nonoperative group, both surgical groups had increased CT% in the medial hindfoot and medial midfoot regions. An increase in lateral hindfoot CT% was observed in the PMR group. In addition, CT% in the first metatarsal region in the PMR group was reduced compared with the nonoperative group. Lateralization is present across both surgical groups in the center of pressure line and hindfoot-forefoot angle. CONCLUSION: While there were minimal differences between surgical groups, patients who underwent PR exhibited pressure variables that were more comparable to the nonoperative group while the PMR group had greater deviations. LEVEL OF EVIDENCE: Level II-therapeutic.

Functional Outcomes Following Treatment for Clubfoot: Ten-Year Follow-up.

BACKGROUND: The purpose of this study was to assess function, at the age of 10 years, of children initially treated nonoperatively for clubfoot with either the Ponseti or French physiotherapy program and to compare outcomes in feet that had undergone only nonoperative treatment with those that required subsequent surgery. METHODS: Gait analysis, isokinetic ankle strength, parent-reported outcomes, and daily step activity data were collected when patients who had been treated for idiopathic clubfoot reached the age of 10 years. Patients who had undergone only nonoperative treatment were compared with those who subsequently underwent extra-articular surgery or intra-articular surgery (posterior release or posteromedial release). The clubfoot groups were compared with age-matched controls. RESULTS: Of 263 treated clubfeet in 175 patients, 148 had only been treated nonoperatively, 29 underwent extra-articular surgery, and 86 underwent intra-articular surgery (posterior release in 42 and posteromedial release in 44). Significant abnormalities were found in ankle kinetics and isokinetic ankle strength in the feet treated with intra-articular surgery compared with the nonoperatively treated feet (p < 0.017). Compared with controls (n = 40 feet), all groups showed reduced ankle plantar flexion during gait, resulting in a deficit of 9% to 14% for dynamic range of motion, 13% to 20% for ankle moment, and 13% to 23% for power (p < 0.013). Within the intra-articular group, feet that underwent posteromedial release had decreased plantar flexion strength (15%; p = 0.008), dorsiflexion strength (6%; p = 0.048), and parent-reported global function scores (p = 0.032) compared with the posterior release group. The patients with clubfoot took 10% fewer steps (p = 0.015) and had 11% less total ambulatory time (p = 0.001) than the controls. CONCLUSIONS: Examination of patients when they had reached the age of 10 years showed better ankle power and isokinetic strength for clubfeet treated without surgery compared with those that underwent intra-articular surgery for residual deformity or recurrence. Compared with controls, both nonoperatively and surgically treated clubfeet had significant limitations in ankle plantar flexion resulting in decreased range of motion, moment, and power. Gastrocnemius-soleus complex strength was decreased after both nonoperative and surgical treatment of clubfeet. Although activity was diminished in the clubfoot population, no differences in function were perceived by the patients' parents. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Gross Motor Function at 10 Years of Age in Children With Clubfoot Following the French Physical Therapy Method and the Ponseti Technique.

PURPOSE: To evaluate gross motor skills [Bruininks-Oseretsky Test of Motor Proficiency, 2nd ed (BOT-2)] of patients with idiopathic clubfoot initially treated nonoperatively with either the French functional physical therapy (PT) method or the Ponseti technique, at age 10 years. METHODS: The BOT-2 was administered by trained physical therapists on patients with idiopathic clubfoot at age 10 years. The cohort was divided by initial treatment method (PT or Ponseti), and compared. Subsequent analyses included comparisons of: initial clubfoot severity (Dimeglio scores: ≤13 vs. >13), laterality (unilateral vs. bilateral), and surgical versus nonoperative outcome. RESULTS: Of the 183 patients tested, 172 were included. The Ponseti and PT groups did not significantly differ according to age, height, weight, body mass index, ankle dorsiflexion, sex, average initial Dimeglio score, laterality, or surgical versus nonsurgical outcome. Overall, patients with treated clubfoot had average gross motor BOT-2 scores compared with age-matched peers. Patients in the PT group scored higher on Running Speed/Agility (P=0.019), Body Coordination percentile rank (P=0.038), and Strength and Agility percentile rank (P=0.007) than patients treated by the Ponseti technique. Patients with bilateral clubfoot scored significantly lower on the Balance subtest (P<0.01), and Body Coordination percentile rank (P<0.01), than those with unilateral clubfoot. Patients who required surgery scored significantly lower on the Balance subtest (P=0.04) than those who did not require surgery. CONCLUSIONS: Clubfoot may impair balance in 10 year olds with bilateral involvement and those requiring surgery. Future research should evaluate whether components of the PT method may improve gross motor outcomes as a supplement to the Ponseti technique. LEVELS OF EVIDENCE: Level II.

Clubfoot Does Not Impair Gross Motor Development in 5-Year-Olds.

PURPOSE: To evaluate the gross motor development of 5-year-olds using the Peabody Developmental Motor Scales, 2nd Edition (PDMS-2), test after initial nonoperative management of clubfoot as infants. METHODS: The PDMS-2 Stationary, Locomotion, and Object Manipulation subtests were assessed on 128 children with idiopathic clubfeet at the age of 5 years. Children were categorized by their initial clubfoot severity as greater than 13, unilateral or bilateral involvement, and required surgery. RESULTS: Children with treated clubfeet had average gross motor scores (99 Gross Motor Quotient) compared with age-matched normative scores. Children with more severe clubfeet required surgery significantly more than children with less severe scores (P < .01). Peabody scores were not significantly different according to initial clubfoot severity, unilateral versus bilateral involvement, and surgical versus nonsurgical outcomes. CONCLUSIONS: Clubfoot does not significantly impair gross motor development in 5-year-olds.

How Is Pulmonary Function and Exercise Tolerance Affected in Patients With AIS Who Have Undergone Spinal Fusion?

STUDY DESIGN: Prospectively enrolled AIS patients who underwent spinal fusion, with 2 year follow-up. OBJECTIVES: To evaluate the cardiovascular fitness and activity level in patients with AIS pre- and post-spinal fusion and to determine if initial curve magnitude or pulmonary function is predictive of exercise capacity. SUMMARY OF BACKGROUND DATA: Researchers have tried to link pulmonary function testing (PFT) to exercise capacity; the results are mixed. Some report no improvement in PFTs or aerobic activity after surgical correction, and PFT measures were not predictive of exercise capacity. Conflicting results have shown Vo2max results to fall within normal range in AIS patients while PFTs show minimal impairment. METHODS: AIS patients underwent PFT and oxygen consumption (VO2) testing during a submaximal graded exercise test (GXT) pre- and post-spinal fusion. Vo2max was predicted in those patients who completed the test to 85% of maximal heart rate. Pre- to postoperative changes were assessed and then compared to age-matched control subjects. Correlations between Vo2max and curve severity, pulmonary function, and activity level were assessed. RESULTS: Thirty-seven patients participated. Vo2max was predicted in 23 patients pre- and postoperation. There was a significant reduction in Vo2max postfusion (39.5 ± 6.5 mL/kg/min vs 42.1 ± 8.1 mL/kg/min, p = .033); however, compared with controls (40.5 ± 6.5 mL/kg/min), all data were within the normal range (p > .05). AIS patients reporting high activity had significantly greater Vo2max than those reporting low activity both pre and postoperatively, but this difference only met statistical significance preop (p < .05). Curve magnitude and PFT measures were not found to correlate with Vo2max (p > .05). CONCLUSIONS: Vo2max in patients with AIS is within normal range both pre- and postfusion. Pulmonary limitations are accommodated for with a slightly increased breathing rate and a slightly reduced overall workload. Activity level rather than curve severity affects Vo2max outcomes following fusion in AIS.

Plantar Pressures After Nonoperative Treatment for Clubfoot: Intermediate Follow-up at Age 5 Years.

INTRODUCTION: Worldwide, a nonoperative approach in the treatment of idiopathic clubfoot has been taken in an attempt to reduce the incidence of surgical outcomes. Although both the Ponseti casting (Ponseti) and the French physiotherapy (PT) methods have shown gait and pedobarograph differences at age 2 years, improved gait results have been reported by age 5 years. The purpose of this study was to assess plantar pressures in feet treated with the Ponseti versus the PT methods at this intermediate stage. METHODS: Clubfoot patients treated nonoperatively (Ponseti or PT) underwent pedobarograph data collection at age 5 years. The foot was subdivided into the medial/lateral hindfoot, midfoot, and forefoot regions. Variables included Peak Pressure, Maximum Force, Contact Area%, Contact Time%, Pressure Time Integral, the hindfoot-forefoot angle, and displacement of the center of pressure (COP) line. Twenty controls were used for comparison. RESULTS: Pedobarograph data from 164 patients (238 feet; 122 Ponseti and 116 PT) showed no significant differences between the Ponseti and the PT feet, except the PT feet had a significantly less medial movement of the COP than the Ponseti feet (P=0.0379). Compared with controls, both groups had decreased plantar pressures in the hindfoot and first metatarsal regions, whereas the midfoot and lateral forefoot experienced significant increases compared with controls. This lateralization was also reflected in the hindfoot-forefoot angle and the COP. CONCLUSIONS: Feet that remain nonoperative and avoid surgical intervention are considered a good clinical result. However, pedobarograph results indicate mild residual deformity in these feet despite clinically successful outcomes. LEVEL OF EVIDENCE: Level II-therapeutic.

Exercise Tolerance in Children With Early Onset Scoliosis: Growing Rod Treatment "Graduates".

STUDY DESIGN: Prospectively enrolled early-onset scoliosis (EOS) patients undergoing growing rod treatment, who have had no surgery for >1 year and/or have received definitive fusion (growing rod "graduates"). OBJECTIVES: To assess oxygen consumption during exercise and determine if a diminished conventional pulmonary function test (PFT) correlates with metabolic, pulmonary, and cardiovascular measures during exercise. SUMMARY OF BACKGROUND DATA: Based on clinical impression and sequential PFT values, EOS patients who have undergone extensive treatment are thought to have limited capacity during exercise. The use of PFTs in this population has been a primary outcome measure of respiratory capacity; however, PFTs are dependent on effort, and thus subjective. This led us to find a new assessment of outcome, to better understand their pulmonary capacity. METHODS: Patients underwent oxygen consumption (VO2) testing while walking at self-selected speed over-ground and during a graded exercise test. Maximal VO2 was predicted in those who completed the test to 85% of maximal heart rate (HR). Statistical analysis included Mann-Whitney U test and Spearman correlation coefficient (α = 0.05). RESULTS: 12 patients participated. Over-ground walking showed that EOS graduates chose to walk at the same speed, but at a higher VO2 Cost (0.28 mL/kg/m) than controls (0.22 mL/kg/m; p < .001). Treadmill exercise testing showed 9 of 12 subjects able to complete the 85% of predicted maximum protocol. The EOS group had lower VO2 during the final stage (27.9 mL/kg/min) compared to controls (34.2 mL/kg/min; p = .021); however, their heart rate reached the same values. Subjects completing the protocol had lower predicted VO2 max (38.5 mL/kg/min) compared with controls (45.0 mL/kg/min), but this was not significant. CONCLUSIONS: Although PFT data suggest clinically relevant pulmonary compromise in EOS patients, the current study shows that these children are able to keep up with their peers in daily activities and also have the capacity to exercise. LEVEL OF EVIDENCE: Level II, therapeutic.

The Relationship Between Gait, Gross Motor Function, and Parental Perceived Outcome in Children With Clubfeet.

BACKGROUND: Assessment of children treated nonoperatively for idiopathic clubfoot, has primarily focused on the kinematic and kinetic results measured with gait analysis (GA). Excellent results in ankle motion and push-off power during gait have been reported at age 5; however, the assessment of gross motor function, has not been evaluated. The purpose of this study was to look at the relationship between gait measures, Peabody Developmental Motor Scales and parent-perception of their child's outcome [measured with the Pediatric Outcomes Data Collection Instrument (PODCI)]. METHODS: A total of 81 children with idiopathic clubfoot were seen for both GA and Peabody testing. Children who initially underwent the Ponseti technique (n=29), the French Physical Therapy method (PT) (n=23), and a group of children initially treated nonoperatively, but who required surgical intervention before GA at 5 years of age (n=29) were enrolled. Pearson's correlation coefficient was used to establish significant relationships between gait variables, Peabody, and PODCI scores. RESULTS: Gait data showed that the Ponseti treated feet had significantly greater ankle power than feet treated surgically (P=0.0075). The Peabody results showed that the PT feet had higher stationary (P=0.0332) and overall gross motor quotient percent (GMQ%) scores (P=0.0092) than the surgical feet. No differences were found in PODCI scores. Ankle power was weakly correlated to the GMQ% (r=0.29; P=0.0102); however, the GMQ% showed a strong correlation to the parent report of Global Functioning Scale on the PODCI (r=0.48; P=0.0005). CONCLUSIONS: Minimal gait disturbances do not interfere with function or parental assessment of abilities and satisfaction at 5-year follow-up in children with idiopathic clubfeet. Nonoperative correction of clubfeet should be the goal when possible, as the Peabody scores show better function as early as 5 years of age when surgery is not required.

A Longitudinal Review of Gait Following Treatment for Idiopathic Clubfoot: Gait Analysis at 2 and 5 Years of Age.

BACKGROUND: Initial correction following nonoperative (NonOp) treatment for idiopathic clubfoot has been reported in 95% of feet by age 2; however, by age 4, approximately one third of feet undergo surgery due to relapse. The purpose of this study was to assess the longitudinal effect of growth and surgical (Sx) intervention on gait following NonOp and Sx treatment for clubfoot. METHODS: Children with idiopathic clubfoot were seen for gait analysis at 2 and 5 years of age. Kinematic data were collected at both visits, and kinetic data were collected at age 5 years. Group comparisons were made between feet treated with the Ponseti casting technique (Ponseti) and the French physical therapy method (PT) and between feet treated nonoperatively and surgically. Comparisons were made between feet treated with a limited release or tendon transfer (fair) and those treated with a full posteromedial release (poor). The α was set to 0.05 for all statistical analyses. RESULTS: Gait data from 181 children with 276 idiopathic clubfeet were collected at both age 2 and 5 years. Each foot was initially treated with either the Ponseti (n=132) or PT (n=144) method but by the 5-year visit, 30 Ponseti and 61 PT feet required surgery. Gait outcomes showed limitations primarily in the Sx clubfeet. Normal ankle motion was only present in 17% of Ponseti and 21% of PT feet by age 5 following Sx management. Sx PT feet showed persistent intoeing at age 2 and 5. Within the Sx group, feet initially treated with PT had a clinically significant reduction in ankle power compared with those treated initially by the Ponseti method. Feet treated with posteromedial releases had significantly less ankle power than those treated with limited surgery or that remained NonOp at 5 years. CONCLUSIONS: This longitudinal study shows subtle changes between 2 and 5 years, and continues to support a NonOp approach in the treatment of clubfoot. LEVEL OF EVIDENCE: Level II-therapeutic.

Intensity and duration of activity bouts decreases in healthy children between 7 and 13 years of age: a new, higher resolution method to analyze StepWatch Activity Monitor data.

Assessment of physical, ambulatory, activity using accelerometer-based devices has been reported in healthy individuals across a wide range of ages, as well as in multiple patient populations. Many researchers who utilize the StepWatch Activity Monitor (SAM) rely on the default settings for data collection and analysis. A comparison was made between the standard output from the SAM software, and a novel method to evaluate all walking bouts using an Intensity-Duration-Volume (I-D-V) model in healthy children aged 7-13. 105 children without impairment wore the SAM for a total of 1691 d. Statistically significant differences were seen between 7-8-9 year olds and 10-11-12 year olds using the I-D-V model that were not seen using the standard SAM software default output. The increased sensitivity of this technique could be critical for observing the effect of various interventions on patients who experience physical limitations. This new analytical model also allows researchers to monitor activity and exercise-type behavior in a way which coincides with exercise prescription by assessing intensity, duration and volume of activity bouts.

Comparison of gait after Syme and transtibial amputation in children: factors that may play a role in function.

BACKGROUND: Preservation of maximal limb length during amputation is often recommended to maximize the efficiency and symmetry of gait. The goals of this study were to determine (1) whether there are gait differences between children with a Syme (or Boyd) amputation and those with a transtibial-level amputation, and (2) whether the type of prosthetic foot affects gait and PODCI (Pediatric Outcomes Data Collection Instrument) outcomes. METHODS: Sixty-four patients (age range, 4.7 to 19.2 years) with unilateral below-the-knee prosthesis use (forty-one in the Syme group and twenty-three in the transtibial group) underwent gait analysis and review of data for the involved limb. The twelve prosthetic foot types were categorized as designed for a high, medium, or low activity level (e.g., Flex foot, dynamic response foot, or SACH). Statistical analyses were conducted. RESULTS: Kinematic differences of <4° in total prosthetic ankle motion and 8° in external hip rotation were seen between the Syme and transtibial groups. Ankle power was greater in the transtibial group, whereas the Syme group had greater coronal-plane hip power (p < 0.05). Prosthetic ankle motion was significantly greater in the high compared with the medium and low-performance feet. However, the PODCI happiness score was higher in patients with low compared with medium-performance feet (p < 0.05). CONCLUSIONS: Small differences in prosthetic ankle motion and power were found between children with Syme and transtibial amputations. Ankle motion was greater in patients using high-performance feet (9% of the total cohort) compared with medium-performance (59%) and low-performance (31%) feet. Despite the increased ankle motion achieved with high-performance dynamic feet, this advantage was not reflected in peak power of the prosthetic ankle or the PODCI sports/physical functioning subscale. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.