[Informative value of the popliteal angle in walking cerebral palsy children]. / Peut-on se fier à l'angle poplité chez l'enfant paralysé cérébral marchant?

PURPOSE OF THE STUDY: In clinical practice, it is generally accepted that hamstring tightness results in incomplete knee extension when the hip is in flexion and in smaller conventional and modified popliteal angles. Similarly, a difference between the conventional popliteal angle and the modified popliteal angle (popliteal differential) would be associated with a permanent deficit in knee extension. The purpose of this study was to determine whether these two hypothesis correlate with clinical findings. MATERIAL AND METHODS: The series was composed of 35 walking cerebral palsy children, 16 girls and 19 boys, mean age 11+/-3.6 years with a pathological conventional popliteal angle. These children walked using the jump knee (n=24) or the crouch knee (n=11) pattern. Permanent hip flexion and the conventional and modified popliteal angles were noted. SPSS version 10.1.3 for Window was used to search for a correlation between the popliteal differential and the presence of permanent hip flexion using several values for the popliteal differential (5, 10, 15, 20, and 30 degrees ). Data were adjusted for age and gender. RESULTS: The statistical analyses demonstrated a significant relationship between the presence of permanent hip flexion and a popliteal differential strictly less than 10 degrees and between the absence of permanent hip flexion and a popliteal angle greater or equal to 10 degrees . These statistically significant results, which demonstrated the opposite of what was expected, were independent of age and gender. DISCUSSION: Our findings demonstrate that examination of the knee joint is indispensable but insufficient. The conventional popliteal angle is not a reliable indicator of hamstring tightness. The normal value of the modified popliteal angle has not been established so that it is impossible to determine what a pathological angle is. We do not know whether measurement of this angle is sufficient to establish indications for surgery. In the future, the development of muscle models coupled with gait analysis should enable more reliable prediction of outcome after surgery. At the present time, we recommend repeated physical examination using a standardized protocol, taking into consideration, several parameters including spasticity, selectivity and muscle force and to perform quantified gait analysis before scheduling hamstring lengthening surgery for walking cerebral palsy children.

Planovalgus foot deformity in cerebral palsy corrected by botulinum toxin injection in the peroneus longus: Clinical and radiological evaluations in young children.

BACKGROUND: In children with cerebral palsy (CP), overactivity of the peroneus longus (PL) muscle is a major contributor to pes planovalgus. This retrospective study assessed whether abobotulinumtoxinA injections into a PL showing premature activity on electromyography (EMG) clinically improved foot morphology in children with CP. METHODS: Study participants were <6 years old, had a diagnosis of CP, good functional abilities (Gross Motor Function Classification System level 1 or 2), equinovalgus (initial contact with the hallux or head of the first metatarsal) and overactive PL on EMG. The fore-, mid- and hindfoot were evaluated clinically and radiologically before and after injection of abobotulinumtoxinA (6-7 U/kg) into the PL. Radiological data were compared with reference values for children without pes planovalgus. RESULTS: In total, 16 children (8 males; 10 hemiplegia, 6 diplegia; mean age: 3.2±1.5 years) received treatment. Mean pre-and post-treatment angles in clinical assessment of dorsiflexion of the talocrural articulation did not differ with both knees flexed (24.4±7.5 vs. 22.2±8.0 degrees; P=0.19) or extended (17.2±8.0 vs. 16.6±6.8 degrees; P=0.36). Radiographic data pre-treatment versus reference data revealed forefoot pronation (metatarsal stacking angle 2.1±8.3 vs. 8.0±2.9 degrees; P=0.002), midfoot planus (lateral talo-first metatarsal 28.5±15.0 vs. 13.0±7.5 degrees; P<0.001; talocalcaneal angle 54.6±8.6 vs. 49.0±6.9 degrees; P=0.004) and significantly decreased calcaneus dorsiflexion, without hindfoot equinus (calcaneal pitch angle 7.9±6.0 vs. 17.0±6.0 degrees; P<0.001). After treatment, the metatarsal stacking angle did not differ from reference values (P=0.15). As compared with before treatment, treatment improved mean angles for metatarsal stacking (2.1±8.3 vs. 7.1±3.9 degrees, respectively, P=0.002), lateral talo-first metatarsal and talocalcaneal (both P<0.001), with no change in the hindfoot. CONCLUSION: PL may be an early target for abobotulinumtoxinA treatment in pes planovalgus associated with premature PL activity in children with CP.

Aneurysmal bone cyst in children: analysis of twenty-seven patients.

The authors have analyzed a retrospective series of 27 aneurysmal bone cysts (ABCs) in children and adolescents. The average age at diagnosis was 10 years (range: 3 years 7 months to 16 years), with a mean follow-up of 5 years (range: 1 month to 13 years 9 months). Pathologic fractures (8 cases) and pain (8 cases) were the main reasons for consultation. Of five spinal ABC patients, four presented with neurologic involvement. Although conventional radiology is useful for diagnosing ABCs, magnetic resonance imaging (MRI) is nevertheless the most important technique for checking the extent of the lesions. However, the diagnosis still must be based on the pathologic laboratory findings, even though this is sometimes difficult because of associated lesions. In lesions of the long bones, recurrence was observed after curettage in 5 of 12 cases. For this reason, simple resection or resection with reconstruction is recommended rather than curettage whenever possible. When an ABC is in contact with the growth plate in young children, blunt curettage should be performed to preserve the child's growth potential. Subsequent recurrence usually is easier to treat than an epiphysiodesis bridge and its consequences. The surgical procedures used to preserve the growth plate are described, along with methods of bone construction after surgery.

[Tomodensitometric aspects of hip luxation in childhood. Apropos of 100 hips]. / Aspects tomodensitométriques de la hanche de l'enfant dans la maladie luxante. A propos de 100 hanches.

One hundred hips in children were examined by computer assisted tomography. They were either dysplastic, subluxated or dislocated. The study resulted in more precision as to the degree of femoral anteversion and acetabular anteversion. The indications for femoral or pelvic osteotomy can thus be more accurate. Mechanical effects of some pelvic osteotomies have been analysed.

[Surgical treatment of congenital dislocation of the hip in older children; analysis of the results. Apropos of 46 cases]. / Traitement chirurgical de la luxation congénitale de hanche du grand enfant; analyse des résultats. A propos de 46 cas.

The results of surgical treatment of 46 congenital dislocations of the hip in children older than 4 years are analysed. Several techniques were used; progressive traction for a short time, stabilisation by plaster cast immobilisation or surgical reduction, pelvic osteotomy with or without combined femoral rotation osteotomy with shortening. Apart from other means of assessment, 3 radiological signs were used to determine the results - sphericity of the femoral head, coverage of the femoral head and centering of the femoral head. A new classification is proposed by the authors. Only 25 p. 100 of the results were excellent or good. The other hips had at least one radiological anomaly and 17.5 p. 100 of the hips had a non-spherical head. Cases with poor coverage of the femoral head did well when this was the only defect because this anomaly was easily corrected. In contrast, excentration of the femoral head was poorly tolerated in the long term. The degree and direction of excentration had to be assessed in the frontal plane.

[The treatment of old dislocations of the radial head in children by osteotomy of the upper end of the ulna. Apropos of 15 cases]. / Le traitement des luxations anciennes de la tête radiale chez l'enfant par l'ostéotomie haute du cubitus. A propos de 15 cas.

Fifteen old dislocations of the radial head in children were treated by open reduction combined with a high osteotomy of the ulna and a reconstruction of the annular ligament. This method, described by the authors in 1978, was used in nine post-traumatic, three congenital, two paralytic and one dislocation associated with multiple exostoses. Twelve children were reviewed with a follow-up of two to 11 years. Nine radial heads remained stable and well reduced. The three congenital dislocations recurred. Eight elbows showed normal alignment and the other four were only improved. Ten elbows had normal movement or better movement than before the operation. Eleven children used their elbow normally or better than before. In all, 14 children were improved, and only one elbow had unaltered function. The results obtained in congenital dislocations should be able to be improved by a number of technical precautions.

[Progressive forearm lengthening in children: 14 cases]. / Les allongements progressifs de l'avant-bras chez l'enfant.

PURPOSE OF THE STUDY: There are few indications for forearm lengthening in children. Several techniques have been proposed. We report our experience with progressive lengthening of the forearm in children using a unilateral axial external fixator and an improved technique consisting in initial insertion of an intramedullary guide wire. MATERIAL AND METHODS: Since 1990, we performed 14 forearm lengthenings in 9 children. Radial agenesia (5 forearms in 4 children), and hereditary multiple exostosis (3 forearms in 2 children) were the predominant causes. The ulna was involved in 9 cases and the radius in 5. Age at initiation of the lengthening procedure ranged from 4.5 to 14.8 years (mean 9.9). The lengthening technique consisted in a transverse subperiosteal osteotomy of the bone shaft then progressive distraction with a unilateral axial external fixator. When axial deviation had to be corrected, we used a subtraction osteotomy. In our last 10 cases, we inserted an intramedullary guide wire in the lengthened bone. The external fixation was left in place throughout the lengthening procedure and until complete bone healing. Serial radiographs were used to assess bone healing, the degree of lengthening achieved and any axial deviation at the end of lengthening. RESULTS: All 14 forearms were reviewed at a mean 50.6 months. Mean lengthening was 26.4 mm (range 10 - 52 mm). There were no nerve or vessel complications. In one case, reducible claw finger completely regressed after temporary interruption of the lengthening. There were 6 cases of late healing requiring a secondary bone graft. The healing index was 61.9 days per cm gained length. There were 3 cases with an axial deviation at the end of lengthening. DISCUSSION: Insertion of a guide wire in the bone being lengthened reduced the risk of late healing compared with lengthening procedures without a guide wire, avoiding axial deviation. In addition, this technique led to more rapid bone healing so the fixator could be removed earlier. We have found this method to be easier to perform on a normally axed segment. This would require an initial subtraction osteotomy for prior alignment. CONCLUSION: Forearm lengthening is a difficult procedure. Use of an intramedullary guide wire associated with an external fixation and an initial osteotomy for axial correction when needed and possibly stabilization of the wrist is an important contribution, particularly for malformed forearms.

[Sagittal equilibrium of the pelvis: analysis of the inclination of the ischio-pubic ramus from the horizontal]. / Equilibre sagittal du bassin : analyse de l'inclinaison de la branche ischio-pubienne par rapport à l'horizontale.

PURPOSE OF THE STUDY: The sagittal equilibrium of the spine and pelvis has been examined in numerous studies looking for the origin of certain posture disorders of the spine and the cause of lower back pain. Sagittal x-rays of the pelvis provide an analysis of the degree of inclination of the pelvis from the horizontal and the bi-coxo-femoral axis and information on the form of the sacrum. There is no radiographic parameter however which analyzes the transition between the pelvis-sacrum component and the femoral component, i.e. the periacetabular region. In the sagittal plane, a line tangent to the ischio-pubic ramus would appear to best reflect the orientation of the periacetabular region and the muscular forces applied to this region. The purpose of this work was to analyze the inclination of the ischio-pubic ramus from the horizontal and its relations with other sagittal radiographic parameters in a population of growing children with spinal disorders. MATERIALS AND METHOD: The study population included 100 children with spinal disorders who underwent a teleradiographic series with lateral view in the upright position. Most of the children had scoliosis (80 cases), 7 had kyphoscoliosis, 4 isthmic spondylolysis with spondylolisthesis, 1 spondylodiscitis and 4 lower back pain. Mean age was 13 years (range 2.5-22 years). We measured 7 radiographic parameters: lumbo-sacral angle, slope of the sacrum, pelvic version, incidence, thickness, overhang, and inclination of the ischio-pubic ramus from the horizontal. Data were analyzed to search for correlations between radiographic parameters and between radiographic parameters and clinical features. RESULTS: Mean inclination of the ischio-pubic ramus from the horizontal was 33.9 degrees (SD =5.9 degrees ). The only positive statistical correlation between the inclination of the ischio-pubic ramus and the clinical data was a relationship with the position of the arms compared with the horizontal (p =0.04). There was no correlation with age, sex, ethnic background, etiology. There was no correlation between the inclination of the ischio-pubic ramus and the other radiographic parameters (coefficient r ranging from 0.06 to 0.43). DISCUSSION: The interdependence of sagittal radiographic parameters of the pelvis and the spine have been largely demonstrated. Certain pathological situations (isthmic spondylolysis with spondylolisthesis, lower back pain, etc.) can be explained by the value of these parameters, particularly incidence. The inclination of the ischio-pubic ramus from the horizontal reflects the periacetabular region. When analyzed in the sagittal plane, it was found to be a more stable parameter, independent of most clinical criteria (particularly age, and etiology) and of the other radiographic parameters studied. The only determining factor appears to be acquisition of the upright position. The consistency of this parameter constrasts with the variability of the other radiographic parameters of the pelvis and the spine, particularly incidence, although the inclination of the ischio-pubis ramus is an expression of a region different than the pelvis. This study suggests that the periacetabular region plays a key role in acquisition of the upright position in humans. The periacetabular region would be a fixed point around which the lower limbs and spine describe varying orientations.

[Total hip arthroplasty without cement in children and adolescents: 17 cases]. / Arthroplastie totale de hanche sur mesure et sans ciment chez l'enfant et l'adolescent: à propos de 17 cas.

PURPOSE OF THE STUDY: Hip disease can produce major pain and functional disorders in children who should benefit from total hip arthroplasty. We report our experience with total hip prostheses implanted without cement in children. MATERIAL AND METHODS: We performed 17 total hip arthroplasties in 13 children who had various conditions, mainly chronic juvenile osteoarthritis and aseptic osteonecrosis secondary to sickle cell anemia. The acetabular inserts were not cemented. All the femoral stems were custom-made using computer-assisted preoperative planning based on standard x-rays and computed tomography findings. Outcome was assessed on the basis of patient satisfaction, pain, and function. Radiographically, we assessed stem implantation, stability and integration. Results were classed with the Harris score and also with the Steinbrocker classification in order to take into account the child's overall functional handicap. RESULTS: Mean follow-up was 36.4 months. There were three cases of superficial hematoma, one case of superficial sepsis and one acetabular loosening. All patients were satisfied. Unsatisfactory function, observed in 80% of the children preoperatively, was found in only 17% postoperatively. The Harris score improved from 23.8 preoperatively to 87.7 at last follow-up. There were no cases of stem loosening and integration was achieved in 85.3% of the cases proximally in the area with hydroxyapatite surfacing. DISCUSSION: The problem with these children is to determine when total hip arthroplasty should be proposed. We retain three important indications: uncontrollable chronic pain, normal school attendance impossible, no other possibility for conservative surgery. Several studies have reported only mediocre results with cemented stems. We opted for custom-made stems without cement for three reasons: preservation of bone stock, better adaptation to bone whose quality and morphology had been remodeled by the underlying condition and repeated osteotomies which also affect the gluteus medius, and finally, better chance of success for future revisions in these active young patients. CONCLUSION: The question on whether or not total hip arthroplasty should be performed early in these children to avoid osteotomies which could alter the longevity of a future prosthesis remains open. Custom-made stems inserted without cement have provided satisfactory results in our experience. To date, follow-up is too short to compare our results with those obtained by others using cemented stems.

[Femoral anteversion in upper femoral epiphysiolysis in adolescents. Apropos of 25 cases]. / Etude de l'antéversion fémorale dans les épiphysiolyses fémorales supérieures de l'adolescent. A propos de 25 cas.

CT-scan examinations have been performed in 25 children with slipped capital femoral epiphysis (SCFE) and in 127 children in an out-patients orthopaedic consultation. A low femoral anteversion (FA) was present in SCFE. This morphological abnormality, in association with other factors, could explain the production of SCFE at the moment of the most important fragility of the upper femoral growth plate, which is puberty. A statistical analysis showed that the risk of SCFE was distinctly greater, even for the contralateral hip when FA was low.

[Osteopetrosis: diagnostic and therapeutic management. Apropos of 5 cases]. / Ostéopétrose: prise en charge diagnostique et thérapeutique. A propos de 5 cas.

PURPOSE OF THE STUDY: The purpose of this study was to analyse 5 cases of osteopetrosis: 2 dominant and 3 recessive forms. MATERIAL AND METHODS: Among five cases of children suffering from osteopetrosis. There were three malignant and two benign forms. Three children affected by malignant form, received a bone marrow transplantation. RESULTS: Only one child who received a bone marrow transplantation was still alive and cured (one died due to transplantation complications, the other child died accidentally). The two children presenting a benign form were periodically followed for iterative fractures and did not present serious complications. DISCUSSION: Our analysis compared to literature review allows us to insist on bone marrow transplantation. This is the only possibility for these children who were condemned in the past. The frequency of iterative fractures on children presenting a dominant form necessitates medical and orthopedic follow-up. Narrowness of the medullary canal, bone fragility contra indicates intramedullary nailing when fixation is indicated. CONCLUSION: Osteopetrosis is an autosomal metabolic bone disease caused by an anomaly of osteoclasts action. Two main forms exist: the dominant form which is benign, and the recessive form which is malignant. Actually recessive forms can be treated and cured by bone marrow transplantation and the children who were in the past condemned are saved. Children with dominant form must be followed up by an orthopaedic surgeon because of bone weakness. The increase in number of cases detected in immigrant populations with a high rate of consanguineous marriages led us to present this study.

[Role of acetabuloplasty in the treatment of residual cotyloid dysplasia before 4 years of age. Apropos of 14 cases followed over 5 years]. / La place de l'acétabuloplastie dans le traitement des dysplasies cotyloïdiennes résiduelles avant l'âge de 4 ans. A propos de 14 cas suivis plus de 5 ans.

Concerning 14 cases with a follow-up of over 5 years, the authors describe their acetabuloplasty technique which is applied to dysplastic sockets with normal cotyloid cavity anteversion, innominate osteotomy is reserved for cases in which this anteversion is excessive; results have been excellent for 11 cases with adequate lowering of the roof-edge of the cavity and improvement of the C and CE angles as well as satisfactory subsequent bone growth; the result was insufficient in 3 cases in which either the head of the femur was off-centre or deformed by osteochondritis. The age of the patients was between 16 and 37 months. No growth disorder caused by the operation has been observed. Three failures may be related to pre-existing abnormalities in the growing areas of the acetabulum or to ischaemic troubles in the femoral head.

[Acute osteomyelitis of the ilium. A study of 2 cases with review of the literature]. / L'ostéomyélite aiguë de l'aile iliaque. Etude de 2 cas avec revue de la littérature.

The authors have made a review of the literature about two cases of osteomyelitis of the iliac ala. They insist on rarity of the disease and how often the right diagnosis may be delayed because of misleading clinical symptoms. Any tumefaction of the buttock associated with pelvic pain and with an infectious syndrome necessarily evoke an iliac osteomyelitis. The bone scan may be negative which need not exclude the possibility. The evolution may be the formation of intra or extra or sometimes simultaneous sub-periosteal abscesses which must be drained. This is the reason why the authors advise to verify systematically the other side of the ilium by its surgical trepanning in case of a sub-periosteal abscess.

[Lower limb morphotypes. A clinical study in 1401 children]. / Morphotypes des membres inférieurs. Etude clinique chez 1401 enfants.

PURPOSE OF THE STUDY: The purpose of this study was to analyse the repartition between femoral anteversion and tibial torsion from birth to ten years of age in children. MATERIAL: One thousand four hundred and one children ranging from 2 to 13 years age were examined in public schools by the same clinician. METHODS: Qualitative data (foot progression angle, hindfoot aspect, knee position during gait) and quantitative data (femoral anteversion, tibial torsion) were clinically quantified. RESULTS: Repartition of femoral and tibial torsion showed four lower limb morphotypes in normal children. CONCLUSION: Four femoral anteversion and tibial torsion associations are encountered in normal children. Age variation of the lower limb orientation leed to have repetitive examinations in children with in or out-toeing gait in order to make distinction between normal and pathologic gait pattern.

[Acetabular anteversion in congenital luxation of the hip]. / L'antéversion du cotyle dans la luxation congénitale de la hanche.

MATERIAL AND METHOD: Acetabular anteversion angle (AAA) and orientation angle of the iliac bone (AOOI) determined by use of a CT scan were studied in CDH. 55 children with CDH were selected on hip arthrography for this study. Subluxated hips were excluded (i.e. opposite hip of a unilateral CDH is normal). 10 boys and 45 girls with a mean of age of 2 years 1 month (extremes from 1 to 4 years 3 months) were studied. CT scan was performed before any orthopaedic treatment in 3 cases of bilateral luxation and 14 cases of unilateral. In the other cases, time between the end of orthopaedic treatment and CT scan varied between 4 and 18 months. A group of 23 normal children, 10 boys and 13 girls, (mean age of 2 years 10 months) served as reference group. On the selected CT slide we measured AAA, AOOI, IAA and IAP (anterior acetabular index and posterior acetabular index as proposed by Guggenheim). RESULTS: We noted that the orientation of the iliac bone was variable in the two groups. This orientation angle could have higher or lower values. AAA: in bilateral luxation, this angle was higher (16 degrees +/- 5 degrees) than in reference group (13 degrees +/- 4 degrees), p < 0.005. In unilateral luxation there was no statistical difference (14 degrees +/- 4 degrees) with reference group, between normal and pathological side and when CT scan was performed before or after orthopaedic reduction. AOOI: there was no significant difference between bilateral, unilateral or reference group. Correlation analysis showed that AAA and AOOI moved in the same direction. IAA: in bilateral luxation this index was higher (p < 0.001); in unilateral luxation only right luxation showed an higher index (p = 0.002). IAP: no significant difference between the different groups. DISCUSSION: This study shows that there is any typical CT scan aspects of morphologic abnormality in CDH. The lesions of the anterior or posterior acetabular wedge are variable. The orientation of the iliac bone is also variable; we concluded that acetabular anteversion must be analysed depending on the morphologic aspects of the anterior and posterior extremities of the acetabulum and iliac bone orientation.

Dynamic EMG of peroneus longus in hemiplegic children with equinovarus.

OBJECTIVE: In hemiplegic children the appearance of equinovarus is correlated with premature electromyography (EMG) activity of the gastrocnemius medialis (GM) prior to initial contact. The goal was to analyze the onset of EMG activation in the GM and, more particularly, the peroneus longus (PL) in cases of equinovarus: is PL activity likewise premature? MATERIAL AND METHODS: As 15 hemiplegic children (age 5 years±1.5) with equinovarus walked, their PL and GM EMG activity was being recorded. The latter was normalized in terms of gait cycle percentage (0-100%) and detected through semi-automatic selection with activation threshold set at 20µV. A paired t-test compared activation onset of the PL versus the GM muscles. RESULTS: As regards the healthy limb, activity onset of the GM (+14.55%) and the PL (+19.2%) muscles occurred only during the ST. In cases of equinovarus, activation of the GM (-5.2%) and the PL (-6.1%) occurred during the SW and was premature. For each muscle, comparison between the healthy and the hemiplegic side was highly significant (P<0.001). CONCLUSION: Premature PL and GM EMG activity preceding initial contact corresponds not to a disorder secondary to imbalance but rather, more probably, to motor command dysfunction. While the PL consequently contributes to equinus deformity, its possible role in varus genesis is less evident. EMG study needs to be completed by comparing PL and tibialis posterior strength while taking foot bone morphology into full account.

Limb lengthening using ankle joint distraction (arthrodiastasis) followed by arthrodesis. Experience with one case.

Tibial aplasias are difficult entities to manage and sometimes require significant limb lengthening. Preserving the joint is the preferred option in these cases. However, when function is not ensured, lengthening beginning in the joint can be attempted followed by arthrodesis. This report presents the clinical and radiological results of a patient treated with intra-articular lengthening (or arthrodiastasis) associated with talocrural arthrodesis. Although this original technique provided satisfactory results, this surgical program remains complicated.

Influence of clinical and gait analysis experience on reliability of observational gait analysis (Edinburgh Gait Score Reliability).

OBJECTIVES: Treatment complexity of cerebral palsy (CP) patients imposes outcome evaluation studies, which may include objective technical analysis and more subjective functional evaluation. The Edinburgh Gait Score (EGS) was proposed as an additive or alternative when complex instrumented three-dimensional gait analysis is not available. Our purposes were to apply a translated EGS to standard video recordings of independent walking spastic diplegic CP patients, to evaluate its intraobserver and interobserver reliability with respect to gait analysis familiar and not familiar observers. METHODS: Ten standard video recordings acquired during routine clinical gait analysis were examined by eight observers gait analysis interpretation experienced or not, out of various specialities, two times with a two weeks interval. Kappa statistics and intraclass correlation coefficient were calculated. RESULTS: Better reliability was observed for foot and knee scores than in proximal segments with significant differences between stance and swing phase. Significantly better results in gait analysis trained observers underlines the importance to either be used to clinical gait analysis interpretation, or to benefit of video analysis training before observational scoring. CONCLUSION: Visual evaluation may be used for outcome studies to explore clinical changes in CP patients over time and may be associated to other validated evaluation tools.