Toward modeling locomotion using electromyography-informed 3D models: application to cerebral palsy.

This position paper proposes a modeling pipeline to develop clinically relevant neuromusculoskeletal models to understand and treat complex neurological disorders. Although applicable to a variety of neurological conditions, we provide direct pipeline applicative examples in the context of cerebral palsy (CP). This paper highlights technologies in: (1) patient-specific segmental rigid body models developed from magnetic resonance imaging for use in inverse kinematics and inverse dynamics pipelines; (2) efficient population-based approaches to derive skeletal models and muscle origins/insertions that are useful for population statistics and consistent creation of continuum models; (3) continuum muscle descriptions to account for complex muscle architecture including spatially varying material properties with muscle wrapping; (4) muscle and tendon properties specific to CP; and (5) neural-based electromyography-informed methods for muscle force prediction. This represents a novel modeling pipeline that couples for the first time electromyography extracted features of disrupted neuromuscular behavior with advanced numerical methods for modeling CP-specific musculoskeletal morphology and function. The translation of such pipeline to the clinical level will provide a new class of biomarkers that objectively describe the neuromusculoskeletal determinants of pathological locomotion and complement current clinical assessment techniques, which often rely on subjective judgment. WIREs Syst Biol Med 2017, 9:e1368. doi: 10.1002/wsbm.1368 For further resources related to this article, please visit the WIREs website.

Level versus inclined walking: ambulatory compensations in children with cerebral palsy under outdoor conditions.

PURPOSE: To investigate how children with cerebral palsy (CP) adapt their gait to inclined outdoor walking conditions. METHODS: Ten children with CP, Gross Motor Function System level II, and 10 children with typical development participated. Walking velocity, stride length and ankle, knee, hip, and trunk sagittal plane angles were calculated for 4 conditions: indoor walkway, outdoor walkway, and walking up and down a 7° inclined ramp. RESULTS: Gait patterns were unchanged between indoor and outdoor level walking. During up-slope walking, both groups increased hip and knee flexion at foot strike to accommodate the slope. During down-slope walking, both groups increased knee flexion in midstance to lower the body down the slope. Children with CP had greater forward trunk lean (P < .005) during up-slope walking and greater posterior trunk lean during down-slope walking (P < .0001). CONCLUSION: Children with CP adapt to inclined walking conditions similarly to peers but use greater postural adaptations.

Botulinum toxin assessment, intervention and follow-up for paediatric upper limb hypertonicity: international consensus statement.

The primary objective of this paper was to evaluate the published evidence of efficacy and safety of botulinum neurotoxin (BoNT) injections in paediatric upper limb hypertonia (PULH). Secondary objectives included the provision of clinical context, based on evidence and expert opinion, in the areas of assessment, child and muscle selection, dosing, and adjunctive treatment. A multidisciplinary panel of authors systematically reviewed, abstracted, and classified relevant literature. Recommendations were based on the American Academy of Neurology (AAN) evidence classification. Following a literature search, 186 potential articles were screened for inclusion, and 15 of these met the criteria and were reviewed. Grade A evidence was found to support the use of BoNT to reach individualized therapeutic goals for PULH. There is grade B evidence (probably effective) for tone reduction following BoNT injections and grade U evidence (inconclusive) for improvement in upper limb (UL) activity and function. BoNT injections were generally found to be safe and well tolerated with the most common side effect identified as a transient decrease in grip strength.

Subject-specific modelling of lower limb muscles in children with cerebral palsy.

BACKGROUND: Recent studies suggest that the architecture of spastic muscles in children with cerebral palsy is considerably altered; however, only little is known about the structural changes that occur other than in the gastrocnemius muscle. In the present study, Magnetic Resonance Imaging (MRI) and subject-specific modelling techniques were used to compare the lengths and volumes of six lower limb muscles between children with cerebral palsy and typically developing children. METHODS: MRI scans of the lower limbs of two children with spastic hemiplegia cerebral palsy, four children with spastic diplegia cerebral palsy (mean age 9.6 years) and a group of typically developing children (mean age 10.2 years) were acquired. Subject-specific models of six lower limb muscles were developed from the MRI data using a technique called Face Fitting. Muscle volumes and muscle lengths were derived from the models and normalised to body mass and segmental lengths, respectively. FINDINGS: Normalised muscle volumes in the children with cerebral palsy were smaller than in the control group with the difference being 22% in the calf muscles, 26% in the hamstrings and 22% in the quadriceps, respectively. Only the differences in the hamstrings and the quadriceps were statistically significant (P=0.036, P=0.038). Normalised muscle lengths in the children with cerebral palsy were significantly shorter (P<0.05), except for soleus and biceps femoris. No significant relationship was found between normalised lengths and volumes of any muscle in either group. INTERPRETATION: The present results show that lower limb muscles in ambulatory children with cerebral palsy are significantly altered, suggesting an overall mechanical deficit due to predominant muscle atrophy. Further investigations of the underlying causes of the muscle atrophy are required to better define management and treatment strategies for children with cerebral palsy.

Error propagation from kinematic data to modeled muscle-tendon lengths during walking.

Kinematic data from 3D gait analysis together with musculoskeletal modeling techniques allow the derivation of muscle-tendon lengths during walking. However, kinematic data are subject to soft tissue artifacts (STA), referring to skin marker displacements during movement. STA are known to significantly affect the computation of joint kinematics, and would therefore also have an effect on muscle-tendon lengths which are derived from the segmental positions. The present study aimed to introduce an analytical approach to calculate the error propagation from STA to modeled muscle-tendon lengths. Skin marker coordinates were assigned uncorrelated, isotropic error functions with given standard deviations accounting for STA. Two different musculoskeletal models were specified; one with the joints moving freely in all directions, and one with the joints constrained to rotation but no translation. Using reference kinematic data from two healthy boys (mean age 9y 5m), the propagation of STA to muscle-tendon lengths was quantified for semimembranosus, gastrocnemius and soleus. The resulting average SD ranged from 6% to 50% of the normalized muscle-tendon lengths during gait depending on the muscle, the STA magnitudes and the musculoskeletal model. These results highlight the potential impact STA has on the biomechanical analysis of modeled muscle-tendon lengths during walking, and suggest the need for caution in the clinical interpretation of muscle-tendon lengths derived from joint kinematics.

Use of three-dimensional kinematic analysis following upper limb botulinum toxin A for children with hemiplegia.

BACKGROUND AND PURPOSE: To examine whether three-dimensional (3-D) kinematic analysis can detect changes in upper limb tasks (reach and hand-to-mouth) in children with hemiplegia, following upper limb botulinum toxin A injections. METHODS: Ten children with hemiplegic cerebral palsy (7 males, 3 females, aged 9-17 years). Subjects received botulinum toxin A (Botox) injections into elbow forearm muscles combined with 6 weeks of occupational therapy. Participants completed a 3-D kinematic analysis of two upper limb tasks, Melbourne Assessment of Unilateral Upper Limb Function and modified Ashworth scores measured at baseline, 2, 6 and 12 weeks post-injection. RESULTS: Post-injections, elbow flexor muscle tone was reduced for 12 weeks (p < 0.05). Group differences in active range of motion during 3-D analysis tasks could not be demonstrated at any time post-intervention. However, individual analyses found that at 2 weeks post-injection, three subjects had >15 degrees increases in active elbow extension and six subjects showed an increase of >25 degrees in forearm supination during performance of the reach and hand-to-mouth tasks, respectively. CONCLUSIONS: 3-D kinematics can detect changes in active movements during functional tasks following botulinum toxin A injections, suggesting this could be a potential objective outcome measure in a clinical trial.

Virtual reality assessment of technical skill using the Bonedoc DHS simulator.

The Bonedoc DHS simulator is a virtual reality simulator of screw and plate fixation of hip fractures which runs on a standard PC. We hypothesised that the simulator would be able to discriminate between subjects with different levels of operative experience. Three groups (medical students (MSs), basic trainees (BTs), and advanced trainees (ATs)) performed six virtual operations. Measurements included: reduction position, incision length, misplaced drill-holes, final screw placement, X-rays taken, surgical time as well as computer and operative experience. The accuracy, number of X-rays and speed were significantly different between novices and trainee surgeons (p<0.01, p<0.05, p<0.05). Intra-articular screw penetration by the medical students occurred 12 times, basic trainees 6 times and advanced trainees twice (p<0.01, MS vs. trainees). Amongst trainees, the advanced trainees placed the lag screw more accurately and took less X-rays (ns). The basic trainees performed the complete procedure fastest at 6 min compared to ATs at 9 min (p<0.05) but were not as accurate. The Bonedoc DHS simulator provides a means to discriminate between novices and trainee surgeons.

Reliability and validity of an activity monitor (IDEEA) in the determination of temporal-spatial gait parameters in individuals with cerebral palsy.

This study evaluated within- and between-session reliability and validity of temporal-spatial gait parameters derived from the intelligent device for energy expenditure and activity (IDEEA) activity monitor (Minisun, Fresno, CA) in subjects with cerebral palsy, using three-dimensional gait analysis (3-DGA) as the criterion standard. Twenty-five subjects with cerebral palsy (mean age 14.1 years, range 8-23) and 30 control subjects (mean age 14.2 years, range 7-24) completed two 3-DGA, 1 week apart with simultaneous IDEEA data collection. The IDEEA had lower within-session reliability than the 3-DGA for both groups, indicated by greater measurement errors and wider repeatability values for all temporal-spatial parameters. Between-session reliability of 3-DGA was high for both groups with intra-class correlation coefficients (ICC) >0.80. The IDEEA monitor showed high between-session reliability for control subjects (ICC 0.71-0.89), but lower reliability in subjects with cerebral palsy, particularly for walking velocity and stride length (ICC 0.53 and 0.62, respectively). Validity comparison between IDEEA and 3-DGA measures using Bland Altman 95% limits of agreement showed a measurement bias, with the IDEEA over-estimating step and stride length and underestimating cadence in both subject groups compared to 3-DGA. The 95% limits of agreement were smaller in controls (step +/-0.20 m; stride +/-0.27 m; walking velocity +/-0.28 m/s) than in subjects with cerebral palsy (step +/-0.36 m; stride +/-0.37 m; velocity +/-0.58 m/s). Modifications may be necessary to improve the reliability and validity of the IDEEA in children, particularly for use in neurological conditions.

A simulation-based training system for hip fracture fixation for use within the hospital environment.

We report development of a PC-based virtual reality training system for hip fracture fixation that comprises a surgical simulator and an assessment component. The simulator allows hip fracture fixation to be performed on a virtual hip model using two-dimensional radiographic images to guide fracture reduction and implant placement. Ten operative scenarios with increasing complexities of fracture type are available. The face validity of the simulator was tested using a 26 item feedback questionnaire, with answers on a 5 cm visual analogue scale from 'disagree strongly' to 'agree strongly'. Ten study participants, aged 20-50, and with variable levels of surgical skills, each performed six operative scenarios on the simulator before completing the questionnaire. The results showed that the simulator had good face validity, with the majority of subjects stating it provided a realistic view of the operating environment (median score 8.2/10) and that the three-dimensional view provided was all that was required (median score 7.8/10). The subjects considered the simulator was able to test problem solving ability (median score 8.0/10). These results confirm that this simulator achieves good face validity without computationally intensive touch feedback (haptics). Overall, this study demonstrates that non-haptic simulators have a larger role to play in virtual simulation than is currently recognised.

MG132 induced apoptosis is associated with p53-independent induction of pro-apoptotic Noxa and transcriptional activity of beta-catenin.

Noxa is a pro-apoptotic BH3-only member of the Bcl-2 family of proteins that is up-regulated at a transcriptional level by the nuclear protein p53 in response to cellular stresses such as DNA damage or growth factor deprivation. Noxa is able to interact with anti-apoptotic members of the Bcl-2 family and causes release of cytochrome c into the cytosol, leading to the activation of caspases and induction of apoptosis. Here we demonstrate that MG132, a proteasomal inhibitor, rapidly induces Noxa mRNA and protein in two human cell lines, T/C28a and Saos2. The induction of Noxa is associated with a significant reduction in the number of metabolically active cells over the first 24 h of exposure to MG132 and progressive activation of caspase-3, a hallmark of caspase-dependent apoptosis. Partial rescue of the phenotype is observed when cells are transfected with Noxa siRNA prior to treatment with MG132, indicating functional significance of the induction of Noxa. p53 has previously been shown to be non-functional in the T/C28a cell line and is absent by Western blotting in Saos2 cells, suggesting that the induction of Noxa is through a p53 independent mechanism. Western blotting and confocal microscopy showed that total beta-catenin protein is increased in both cell lines at the time of Noxa induction, with the bulk of the beta-catenin present in the nucleus. Transfection with the Tcf reporter vector pTOPFLASH confirms that treatment with MG132 leads to early increased transcriptional activity of beta-catenin in both T/C28a and Saos2 cells. However, although over-expression of transcriptionally active beta-catenin in T/C28a cells also induced apoptosis through a p53-independent mechanism, the levels of Noxa protein were unchanged, suggesting that beta-catenin mediated signaling and Noxa may play independent roles in MG132 induced apoptosis. In summary, our results demonstrate that MG132 induces the pro-apoptotic protein Noxa via a p53-independent mechanism that leads to caspase-dependent apoptosis. This is the first report showing that treatment with MG132 induces Noxa. This study also provides further evidence for a link between beta-catenin mediated signaling and the induction of apoptosis.

Early gene response in lithium chloride induced apoptosis.

Depending on the cellular context, lithium chloride can lead to enhanced proliferation, cell cycle arrest or apoptosis in mammalian cells. Although substantial work has been made to elucidate the downstream events in the case of lithium chloride-induced cellular proliferation, the molecular response to lithium chloride treatment in the apoptotic scenario is largely undefined. We have used quadruplicate human cDNA arrays with 8000 targets to analyze the early gene response in cultures of human T/C28a cells that undergo apoptosis in response to 20 mM lithium chloride treatment. Incubation of cell cultures with 20 mM lithium chloride for five hours caused alterations in the steady-state mRNA levels of a large number of genes. RT-PCR and real-time RT-PCR confirmed the array results for ten of eleven selected targets. In addition to one protein primarily associated with apoptosis, genes identified as differentially expressed based on microarray data mainly encode proteins involved in basic cellular functions such as signaling, cell cycle control and growth, cell-cell interaction, solute transport and transcription control. We present a list of 50 genes that were differentially expressed in response to lithium chloride treatment and which may represent a reference for further studies to define the pathways governing the apoptotic response to lithium chloride.

Flucloxacillin associated neutropenia in children treated for bone and joint infections.

OBJECTIVE: This report describes episodes of acute neutropenia associated with flucloxacillin use in children treated for bone and joint infections. METHODS: A retrospective chart audit was performed on eight children who developed neutropenia when treated with flucloxacillin. RESULTS: Eight children (aged 1 month to 13 years) had a diagnosis of neutropenia attributed to treatment with flucloxacillin, seven of whom received parenteral therapy. The time to onset of neutropenia averaged 27 days, with neutrophil counts returning to normal limits in all patients after 2 to 9 days. Two children were asymptomatic when the neutropenia was detected. The average flucloxacillin dose used was 65% (range 20-100%) of the recommended maximum dose. CONCLUSIONS: These cases suggest that flucloxacillin should be used with greater caution and guidelines for dosing and clinical monitoring (regular neutrophil counts) need to be reassessed, despite none of these patients experiencing serious sequelae.

Inter- and intra-measurer error in the measurement of Reimers' hip migration percentage.

Reimers' hip migration percentage is commonly used to document the extent of subluxation of the hip in children with spasticity. In this study, two measurers, with six months paediatric orthopaedic experience, measured the migration percentage on 44 pelvic radiographs of children with cerebral palsy, aged between two and eight years. Unknown to the measurers, each radiograph was duplicated, giving 22 non-identical radiographs (44 hips) which were measured twice at time 0 and twice six weeks later. The intra-measurer, intra-sessional absolute differences between the first and second measurements ranged from 0% to 23%, with median values of 2.5% to 3.6%. The intra-sessional median absolute differences were not statistically different between the two measurers and measuring sessions (p = 0.42, Kruskal-Wallis test). The inter-sessional absolute differences for measurements made by the same measurers ranged from 0% to 18% with a median absolute difference of 1.7% to 3.2%. Overall, only 5% of the intra-measurer measurement differences, within and between sessions, were above 13%. Repeated measurements by one measurer over time must, therefore, vary by more than 13% in order to be 95% confident of a true change. The inter-measurer error was higher with median absolute differences between the two measurers' measurements of the same hip of 3.25% to 5% (0% to 26%) and a 95th upper confidence interval of 21% to 23%. Averaging the four separate measurements over the two sessions reduced the inter-measurer error to a median absolute difference of 2.8%, but did not improve the 95th upper confidence interval, which measured 22.4%. Such inter-measurer errors may be clinically unacceptable.

Intramedullary fixation for pediatric unstable forearm fractures.

Forty-nine children with diaphyseal both-bone forearm fractures were treated with either both-bone intramedullary wire fixation (24), single ulnar intramedullary wire fixation (22), or single radial intramedullary wire fixation (3). Six fractures were open and 43 were closed. A limited open approach to one or both bones was necessary for insertion of the intramedullary wire in 10 of 43 closed fractures. All both-bone and single radial intramedullary wire fixations healed with less than 5 degrees angulation. Progressive reangulation of the nonfixed radial fracture after an initial satisfactory reduction was seen in seven of the 22 fractures treated with single ulnar intramedullary wire fixation. In four patients, the reangulation was controlled by a change of cast and molding of the fracture and was between 8 degrees and 12 degrees at union. In two other patients a second operative procedure was required to reduce and internally fix the radius. One fracture healed with a radial angulation of 25 degrees. Three fractures in older patients showed late reangulation after early removal of intramedullary wires at 5 weeks. The results of the current study suggest that the radius and ulna should be stabilized with intramedullary wires and that the wires should be buried to reduce the need for early removal.

Genetics of club foot in Maori and Pacific people.

The role of major gene and multifactorial inheritance in the aetiology of club foot in the New Zealand Polynesian population was studied using 287 New Zealand Maori and Pacific club foot families. The club foot family data were analysed by complex segregation analysis under the mixed model using the computer program POINTER. This analysis shows that the best genetic model for club foot in this population is a single dominant gene with a penetrance of 33% and a predicted gene frequency of 0.9%. These data provide a scientific foundation for molecular studies in the Maori and Polynesian population to identify putative club foot genes.

Successive formative stages of precartilaginous mesenchymal condensations in vitro: modulation of cell adhesion by Wnt-7A and BMP-2.

High-density chick limb bud cell culture is a useful model to study mesenchymal condensatifons and chondrogenesis. Most previous studies have focused on the effects of soluble reagents on terminal chondrogenic differentiation and have not defined the early cellular processes and signaling events. In this study, we defined five successive stages in the differentiation process: 1) dissociated cells, 2) small aggregates, 3) formation of cell clusters, 4) precartilaginous condensations, and 5) cartilage nodule. We used RCAS retrovirus-mediated Wnt-7a gene transduction to test the effect of Wnt-7a on the differentiation process. We found that Wnt-7a suppressed chondrogenic differentiation. Wnt-7a did not inhibit the initiation of condensation formation but blocked the progression of precartilaginous condensations to cartilage nodules. The Wnt-7a-transduced cultures showed characteristics of a less mature culture with persistent expression of NCAM, N-cadherin, wider distribution of integrin beta1 and fibronectin, and suppression of tenascin-C. BMP-2 is known to enhance chondrogenic differentiation in these cultures by promoting cell clusters to form continuous sheet-like precartilaginous condensations. However, cultures exposed to both BMP-2 and Wnt-7a showed inhibition of chondrogenic differentiation. Different signaling molecules such as Wnt-7a and BMP-2 may have antagonistic effects on cartilage differentiation and the gradient of the two molecules may be involved in defining the boundaries of the initial precartilaginous condensation. We propose that the shape of the precartilaginous condensations may be modulated by local concentrations of signaling molecules, such as Wnt-7a and BMP-2, which act to alter cell-substrate and cell-cell adhesions.

Wnt-7a in feather morphogenesis: involvement of anterior-posterior asymmetry and proximal-distal elongation demonstrated with an in vitro reconstitution model.

How do vertebrate epithelial appendages form from the flat epithelia? Following the formation of feather placodes, the previously radially symmetrical primordia become anterior-posterior (A-P) asymmetrical and develop a proximo-distal (P-D) axis. Analysis of the molecular heterogeneity revealed a surprising parallel of molecular profiles in the A-P feather buds and the ventral-dorsal (V-D) Drosophila appendage imaginal discs. The functional significance was tested with an in vitro feather reconstitution model. Wnt-7a expression initiated all over the feather tract epithelium, intensifying as it became restricted first to the primordia domain, then to an accentuated ring pattern within the primordia border, and finally to the posterior bud. In contrast, sonic hedgehog expression was induced later as a dot within the primordia. RCAS was used to overexpress Wnt-7a in reconstituted feather explants derived from stage 29 dorsal skin to further test its function in feather formation. Control skin formed normal elongated, slender buds with A-P orientation, but Wnt-7a overexpression led to plateau-like skin appendages lacking an A-P axis. Feathers in the Wnt-7a overexpressing skin also had inhibited elongation of the P-D axes. This was not due to a lack of cell proliferation, which actually was increased although randomly distributed. While morphogenesis was perturbed, differentiation proceeded as indicated by the formation of barb ridges. Wnt-7a buds have reduced expression of anterior (Tenascin) bud markers. Middle (Notch-1) and posterior bud markers including Delta-1 and Serrate-1 were diffusely expressed. The results showed that ectopic Wnt-7a expression enhanced properties characteristic of the middle and posterior feather buds and suggest that P-D elongation of vertebrate skin appendages requires balanced interactions between the anterior and posterior buds.

Community-acquired methicillin-resistant Staphylococcus aureus: a cause of musculoskeletal sepsis in children.

Between August 1996 and August 1997, 130 children were admitted to our pediatric orthopaedic unit with Staphylococcus aureus musculoskeletal infection. Twenty-six of the 130 staphylococcal isolates were resistant to methicillin, an incidence of 20%. All but one of the infections, a femoral fixator-pin infection, were community-acquired. Twenty-two of the infections were superficial; however, there were four cases of deep musculoskeletal sepsis due to methicillin-resistant S. aureus. In areas where methicillin-resistant S. aureus is prevalent in the community, methicillin resistance should be considered in any overwhelming staphylococcal infection not responding to conventional antibiotics despite adequate surgical debridement.

Retroviral gene transfer in chondrogenic limb bud micromass cultures.

We report development of a model of retroviral gene transduction in high-density limb bud cell micromass culture. The replication competent avian retrovirus RCAS BP (A) carrying the human placental alkaline phosphatase gene (RCAS AP) was used as a marker for retroviral infection and spread. The final protocol balances the need to allow time for retroviral integration and gene transduction against loss of chondrogenic potential when limb bud cells are plated at low density. It includes: (i) incubation of the dissociated limb bud cells with RCAS virus for 2 h followed by low-density culture for 48 h to allow retroviral gene expression; and (ii) secondary replating as high-density micromass culture to initiate chondrogenesis. The pattern and level of chondrogenesis in the retrovirus-transduced micromass cultures is similar to regular micromass cultures. At least 40%-50% of cells express the retroviral-transduced genes 24 h after high-density plating. This new approach facilitates ectopic gene expression in micromass culture, enabling molecular dissection of chondrogenesis and serves as a model for gene transduction in other organotypic cultures.