Gait analysis for individually tailored interdisciplinary interventions in children with cerebral palsy: a randomized controlled trial.

AIM: To test the hypothesis that improvements in gait and function following individualized interdisciplinary interventions consisting of physical therapy, orthotics, spasticity management, and orthopaedic surgery using instrumented gait analysis are superior to 'usual care' in children with cerebral palsy (CP). METHOD: This was a prospective, single-blind, parallel-group, randomized controlled trial investigating the effectiveness of interventions based on the use of gait analysis. Primary outcome was gait (Gait Deviation Index) and secondary outcomes were walking and patient-reported outcome measures of function, disability, and health-related quality of life. Follow-ups were done at 26 weeks (questionnaires) and at the primary end point of 52 weeks (all outcomes). RESULTS: Sixty participants with CP (39 males, 21 females, mean age 6y 10mo, standard deviation 1y 3mo, range 5y-9y 1mo) in Gross Motor Function Classification System levels I or II, were randomized to interventions with or without gait analysis. No significant or clinically relevant between-group differences in change scores of the primary or secondary outcomes were found. The recommended categories of interventions were dominated by non-surgical interventions and were applied in 36% to 86% of the participants. INTERPRETATION: Interventions using gait analysis were not superior to 'usual care' on gait, walking, or patient-reported outcomes in a sample of relatively young and independently walking children with CP not expected to need surgery. WHAT THIS PAPER ADDS: Gait analysis in children with cerebral palsy in Gross Motor Function Classification System levels I or II recommends interdisciplinary interventions. Compliance to interventions recommended after gait analysis was low. No statistically significant advantages were identified for the intervention group versus the control group.

ANÁLISIS DE MARCHA PARA LA INTERVENCIÓN INTERDISCIPLINARIA ADAPTADA INDIVIDUALMENTE EN NIÑOS CON PARÁLISIS CEREBRAL: ENSAYO CONTROLADO RANDOMIZADO: OBJETIVO: Comprobar la hipótesis que las mejoras en la marcha y la función luego de las intervenciones interdisciplinarias individualizadas de terapia física, ortésis, tratamiento antiespástico, y cirugía ortopédica son superiores que "tratamiento convencional" en parálisis cerebral (PC) utilizando un análisis de marcha instrumentada METODO: Este fue un ensayo randomizado controlado, prospectivo, ciego, con grupo paralelo que investigó la efectividad de intervenciones basada en el uso de análisis de marcha. El resultado primario fue la marcha (Índice de Desviación de la Marcha) y los resultados secundarios fueron el paso y los resultados reportados por los pacientes de función, discapacidad y calidad de vida relacionada a la salud. Los seguimientos se realizaron a las 26 semanas (cuestionarios) y el punto de fin primario de 52 semanas (todos los resultados). RESULTADOS: Sesenta participantes con PC (39 masculinos, 21 femeninos, edad media de 6 años 10 meses, desviación estándar de 1 años y 3 meses, rango 5 años 0 meses- 9 años y 1 mes) con niveles de GMFCS I o II, fueron asignados al azar intervenciones con y sin análisis de marcha. No se encontraron diferencias significativas o clínicamente relevantes entre los grupos en cuanto a los cambios de los resultados primarios y secundarios. INTERPRETACION: Las intervenciones que usaron análisis de marcha no fueron superiores al tratamiento convencional sobre el paso, la marcha o resultados reportados por los pacientes en una muestra de niños con PC relativamente jóvenes y de marcha independiente que no se espera que necesiten cirugía.

ANÁLISE DE MARCHA PARA INTERVENÇÕES INDIVIDUALMENTE PLANEJADAS EM CRIANÇAS COM PARALISIA CEREBRAL: UM ENSAIO CONTROLADO RANDOMIZADO: OBJETIVO: Testar a hipótese de que melhoras na marcha e função após intervenções interdisciplinares individualizadas consistindo de fisioterapia, órteses, manejo da espasticidade, e cirurgia ortopédica usando análise de marcha instrumentalizada são superiors comparadas ao "cuidado usual" em crianças com paralisia cerebral (PC). MÉTODO: Este foi um estudo randomizado controlado prospectivo, único cego, com grupos paralelos, investigando a efetividade de intervenções baseadas no uso da análise de marcha. O desfecho primário foi a marcha (Índice de Desvio da Marcha) e os desfechos secundários foram o caminhar e medidas relatadas pelo paciente da função, incapacidade, e qualidade de vida relacionada à saúde. Acompanhamentos foram feitos com 26 semanas (questionários) e o encerramento primário foi 52 semanas (todos os resultados). RESULTADOS: Sessenta participantes com PC (39 do sexo masculino, 21 do sexo feminino, média de idade 6a 10 m, desvio padrão 1a 3 m, variação 5a 0 m- 9a 1 m) nos níveis do Sistema de Classificação da Função Motora Grossa (GMFCS) I ou II foram fandomizados para intervenções com ou sem análise de marcha. Nenhuma diferença significativa ou clinicamente relevante entre grupos nos escores de mudança dos desfechos primários e secundários foram encontradas. As categorias de intervenção recomendadas foram dominadas pelas intervenções não-cirúrgicas e foram aplicadas em 36% a 86% dos participantes. INTERPRETAÇÃO: Intervenções usando análise de marcha não foram superiores ao "cuidado usual" para a marcha, o caminhar, ou resultados reportados por pacientes em ma amostra de crianças com PC relativamente jovens e com deambulação indepente, para a qual não se espera a necessidade de cirurgia.

The use of instrumented gait analysis for individually tailored interdisciplinary interventions in children with cerebral palsy: a randomised controlled trial protocol.

BACKGROUND: Children with cerebral palsy (CP) often have an altered gait. Orthopaedic surgery, spasticity management, physical therapy and orthotics are used to improve the gait. Interventions are individually tailored and are planned on the basis of clinical examinations and standardised measurements to assess walking ('care as usual'). However, these measurements do not describe features in the gait that reflect underlying neuro-musculoskeletal impairments. This can be done with 3-dimensional instrumented gait analysis (IGA). The aim of this study is to test the hypothesis that improvements in gait following individually tailored interventions when IGA is used are superior to those following 'care as usual'. METHODS/DESIGN: A prospective, single blind, randomised, parallel group study will be conducted. Children aged 5 to 8 years with spastic CP, classified at Gross Motor Function Classification System levels I or II, will be included. The interventions under investigation are: 1) individually tailored interdisciplinary interventions based on the use of IGA, and 2) 'care as usual'. The primary outcome is gait measured by the Gait Deviation Index. Secondary outcome measures are: walking performance (1-min walk test) and patient-reported outcomes of functional mobility (Pediatric Evaluation of Disability Inventory), health-related quality of life (The Pediatric Quality of Life Inventory Cerebral Palsy Module) and overall health, pain and participation (The Pediatric Outcome Data Collection Instrument). The primary endpoint for assessing the outcome of the two interventions will be 52 weeks after start of intervention. A follow up will also be performed at 26 weeks; however, exclusively for the patient-reported outcomes. DISCUSSION: To our knowledge, this is the first randomised controlled trial comparing the effects of an individually tailored interdisciplinary intervention based on the use of IGA versus 'care as usual' in children with CP. Consequently, the study will provide novel evidence for the use of IGA. TRIAL REGISTRATION: ClinicalTrials.gov NCT02160457 . Registered June 2, 2014.

[Treatment of clubfoot in children].

Congenital talipes equinovarus or clubfoot is a common birth defect which affects the foot and ankle. In most cases, the underlying cause is unknown. The Ponseti method has become the gold standard of treatment for clubfoot. It is a non-invasive technique using series of plaster casts and orthoses. Complementary Achilles tenotomy is usually necessary. However, surgery is generally salvaged for more severe, rigid cases of clubfoot, including syndromic clubfeet arisen in neurological and neuromuscular disorders, which is summarized in this review.

Genetic epidemiology of Scheuermann's disease.

BACKGROUND AND PURPOSE: The genetic/environmental etiology of Scheuermann's disease is unclear. We estimated the heritability of the disease using an etiological model adjusted for sex and time of diagnosis, and examined whether the prevalence of Scheuermann's disease was constant over time. METHODS: 46,418 twins were sent a questionnaire about health and disease. Of these, 75% returned the questionnaire and 97% answered the question "Have you been diagnosed as having Scheuermann's disease by a doctor?" RESULTS: Responders included 11,436 complete pairs of twins. Data were analysed using classical twin modeling methods. Tetrachoric correlations were used to decide which etiological model to fit. The best-fitting model was the AE model. Heritability was 0.74 (95% CI: 0.65-0.81), while variance explained by environmental factors was 0.26 (95% CI: 0.19-0.35). A threshold of 2.1 (95% CI: 1.9-2.2) was calculated, corresponding to a prevalence of 1.9% (95% CI: 1.3-2.8) for women. Regression coefficients for age and sex were 0.000 (95% CI: -0.003 to 0.002) and -0.32 (95% CI: -0.42 to -0.23). INTERPRETATION: We found a heritability of 0.74 in Scheuermann's disease. The threshold in men was lower than in women, corresponding to a male prevalence that was almost twice that of females. We found no change in the prevalence of Scheuermann's disease throughout the 50-year age span that we examined.

Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins.

BACKGROUND: The purpose of this study was to establish a cohort of symptomatic twins with Scheuermann kyphosis to provide estimates of prevalence, concordance, odds ratio, and heritability. These estimates indicate to what extent genetic factors contribute to the etiology of this disease. METHODS: The Odense-based Danish Twin Registry is unique in that it contains data on all 73,000 twin pairs born in Denmark over the last 130 years. For the present study, all 46,418 twins born from 1931 through 1982 received a seventeen-page questionnaire, in which one question was "Have you been diagnosed with Scheuermann disease by a doctor"? The prevalence of self-reported Scheuermann disease was calculated, with the total number of answers used as the general population. Pairwise and probandwise concordance, odds ratio, tetrachoric correlations, and heritability were calculated. RESULTS: We found that the overall prevalence of Scheuermann disease was 2.8%, with a prevalence of 2.1% among women and 3.6% among men (p < 0.0001). The pairwise concordance for monozygotic twins was 0.19 compared with 0.07 for dizygotic twins. The probandwise concordance was 0.31 for monozygotic twins and 0.13 for dizygotic twins. The odds ratios were 32.92 and 6.25 in the monozygotic and dizygotic twins, respectively. These differences were significant (p < 0.01). Heritability was 74%. CONCLUSIONS: In a large cohort of twins that included almost 35,000 individuals, the self-reported overall prevalence of Scheuermann disease was 2.8% and the male-to-female ratio was close to 2:1. Because the pairwise and probandwise concordance and the odds ratio were two to three times higher in monozygotic than in dizygotic twins and the heritability was high, we concluded that there is a major genetic contribution to the etiology of Scheuermann disease.

There are only minor changes in quality of life in patients with Scheuermann's disease.

INTRODUCTION: The impact of Scheuermannss disease (SD) on health-related quality of life (HRQoL) is unclear. The aim of this study was to study HRQoL based on The Medical Outcome Study Short Form-12 (SF-12) in adult life in a group of SD patients. MATERIAL AND METHODS: A total of 46,418 twins were sent a questionnaire. 75.3% answered. Included in the questionnaire were questions from the SF-12. We compared SF-12 values in SD patients and control patients. We also identified 259 "non-concordant" twin pairs and compared SF-12 values from the SD twin with values from the healthy twin. RESULTS: In all, 943 persons were identified to have SD, leaving 33,064 persons in the control group. SF-12 Physical Component Summary (PCS) (mean (standard deviation)) was found to be 50.50 (9.89) in SD and 53.21 (8.00) in controls (p < 0.001), and SF-12 Mental Component Summary (MCS) was found to be 51.52 (8.49) in SD and 51.81 (8.45) in controls (p = 0.71). In the non-concordant twin pairs, SF-12 PCS was found to be 50.74 (9.87) in SD and 52.74 (8.84) in controls (p < 0.001), and SF-12 MCS was found to be 53.91 (8.19) in SD and 53.72 (8.70) in controls (p = 0.64). CONCLUSION: SF-12 PCS is moderately, though highly statistically significantly worse in SD patients than in controls in this big group of twins. We found no statistical difference in SF-12 MCS between the two groups. SD patients evaluate their physical health worse and their mental health like controls. FUNDING: This study was funded by The Sahva Foundation. The sponsor had no influence on the study or its publication. No conflicts of interest exist between the sponsor and the authors. TRIAL REGISTRATION: Approved by the Scientific-ethical Committee in Denmark (no. 20010202).

Heritability of clubfoot: a twin study.

INTRODUCTION: The aetiology of congenital clubfoot is unclear. Although studies on populations, families, and twins suggest a genetic component to the aetiology, other studies have identified environmental factors. The purpose of this study was to calculate heritability in order to determine to what extent genetic and/or environmental factors contribute to the aetiology of congenital clubfoot and to asses whether there was a change in the prevalence over time. MATERIALS AND METHODS: The Odense based Danish Twin Registry is unique as it contains data on all the approximately 85,000 twin pairs born in Denmark over the last 140 years. All 46,418 twin individuals born from 1931 through 1982, who had earlier consented to contact, received a 17-page Omnibus questionnaire in the spring of 2002. Data were analysed with structural equation models to identify the best fitting aetiological model based on a balance of goodness-of-fit and parsimony and to estimate heritability. RESULTS: We found an overall self-reported prevalence of congenital clubfoot of 0.0027 (95 % confidence interval 0.0022-0.0034). Fifty-five complete (both twins answered the question) twin pairs were identified representing 12 monozygotic, 22 same-sex dizygotic, 18 opposite-sex dizygotic, and 3 with unclassified zygosity. The model with only environmental factors (CE) was best fitting based on AIC, and the model with an additive genetic factor (ACE) came in second. Due to the small statistical power, we hypothesise that the model with both genetic and environmental effects (ACE) was the better model. Choosing the ACE-model we found a heritability of clubfoot of 30 %. Regression coefficient for age was -0.002 (-0.011 to 0.005), indicating that there has been no change in prevalence of clubfoot over the 50-year age span we examined. DISCUSSION: We conclude that non-genetic factors must play a role, and a genetic factor might contribute, in the aetiology of congenital clubfoot.

[Stress fracture following femoral epiphysiodesis]. / Stressfraktur efter epifysiodese i femur.

Growth guiding is currently widely practiced for deformity correction in the growing child. Different methods have been developed. In 2007 Stevens described a tension band device (8-plates) as a simple growth control method. Since then it has been widely used, e.g. in hemiepiphysiodesis to correct varus or valgus deformities or extension defect in the knee. Temporary epiphysiodesis can also be used to correct leg length discrepancy more accurately. Complications after treatment with 8-plates are well-described. Stress fracture after the usage of this device has to our knowledge not yet been described. We present a case with a fracture in the distal femur through 8-plates screw holes.

[Purulent coxitis in 8-year-old boy caused by Salmonella enteritidis]. / Purulent coxitis hos 8-årig dreng forårsaget af Salmonella enteritidis.

Salmonella enteritidis is a rare cause of suppurative arthritis of the hip joint in children. The diagnosis is clinical and paraclinical. Treatment is surgical with decompression and antibiotics according to culture. A case of an 8-year-old boy is presented.