Creating an autoencoder single summary metric to assess gait quality to compare surgical outcomes in children with cerebral palsy: The Shriners Gait Index (SGI).

Gait for individuals with movement disorders varies widely and the variability makes it difficult to assess outcomes of surgical and therapeutic interventions. Although specific joints can be assessed by fewer individual measures, gait depends on multiple parameters making an overall assessment metric difficult to determine. A holistic, summary measure can permit a standard comparison of progress throughout treatments and interventions, and permit more straightforward comparison across varied subjects. We propose a single summary metric (the Shriners Gait Index (SGI)) to represent the quality of gait using a deep learning autoencoder model, which helps to capture the nonlinear statistical relationships among a number of disparate gait metrics. We utilized gait data of 412 individuals under the age of 18 collected from the Motion Analysis Center (MAC) at the Shriners Children's - Chicago. The gait data includes a total of 114 features: temporo-spatial parameters (7), lower extremity kinematics (64), and lower extremity kinetics (43) which were min-max normalized. The developed SGI score captured more than 89% variance of all 144 features using subject-wise cross-validation. Such summary metrics holistically quantify an individual's gait which can then be used to assess the impact of therapeutic interventions. The machine learning approach utilized can be leveraged to create such metrics in a variety of contexts depending on the data available. We also utilized the SGI to compare overall changes to gait after surgery with the goal of improving mobility for individuals with gait disabilities such as Cerebral Palsy.

What are the long-term outcomes of lateral column lengthening for pes planovalgus in cerebral palsy?

BACKGROUND: Lateral column lengthening (LCL) is commonly performed on children and adolescents with cerebral palsy (CP) for correction of pes planovalgus (PPV). There are limited reports of the long-term outcomes of this procedure. The purpose of this study was to examine the long-term results of LCL for correction of PPV in individuals with CP by evaluating subjects when they had transitioned to adulthood and were entering the workforce. METHODS: Clinical assessments, quantitative gait analysis including the Milwaukee Foot Model (MFM) for segmental foot kinematics, and patient reported outcomes were collected from 13 participants with CP treated with LCL for PPV in childhood (average age 24.4 ± 5.7 years, average 15.3 ± 8.5 years since LCL). Additionally, 27 healthy adults average age 24.5 ± 3.6 years functioned as controls. RESULTS: Strength and joint range of motion were reduced in the PPV group (p < 0.05). Sixty nine percent showed operative correction of PPV based on radiologic criteria. Gait analysis showed reduced walking speed and stride length, as well as midfoot break and residual forefoot abduction. Patient reported outcomes indicated that foot pain was not the only factor that caused limited activity and participation. LCL surgery for PPV in childhood resulted in long-term operative correction. Decreased ankle passive range of motion and strength, subtalar joint arthritic changes, inefficient and less stable ambulation, and problems with participation (difficulties in physical function, education, and employment) were observed in the long-term. CONCLUSION: This study identified postoperative impairments and limitations to guide future clinical decision-making. These results provide clinicians and researchers the common residual and recurrent issues for these individuals as they age. The inclusion of contextual factors that influence the disease and impairments can equip these individuals with enhanced skills they need as they transition into adulthood.

Gait Characteristics in Youth With Transverse Myelitis.

BACKGROUND: Transverse myelitis (TM) in childhood is a rare disorder characterized by the presence of spinal cord inflammation. Gait difficulty in children with TM is common; however, there is a paucity of literature regarding quantitative assessment of gait in children and adolescents with TM. OBJECTIVES: To characterize gait patterns in a cohort of ambulatory children with TM and age-matched, typically developing peers in order to better understand the functional mobility of patients diagnosed with childhood TM. METHODS: This was a retrospective study of 26 ambulatory pediatric patients with a confirmed diagnosis of TM who had undergone three-dimensional, instrumented gait analysis (3D-IGA) at 3 years of age or older. A group of 38 typically developing children served as a control group. RESULTS: Gait in children with TM was characterized by moderate kinematic deviations as measured by the Gait Deviation Index (GDI) and a crouched gait pattern (p < .001), increased anterior pelvic tilt (p < .001), decreased motion at the knees (p < .001), and a wider base of support (foot progression angle, p < .001). The TM group had a slower walking speed (p < .001), shorter strides (p < .001), and an increased stance phase compared to controls. CONCLUSION: Our study results showed moderate kinematic deviations quantified by the GDI. Overall, the gait pattern in the TM population tested had greater hip and knee flexion with wider foot progression angle. Identification of gait characteristics in children with TM is the first step in predicting changes in gait pattern as they mature over time, which may ultimately allow for targeted intervention to maintain their ambulatory function.

A Long-term Follow-up of Young Adults With Idiopathic Clubfoot: Does Foot Morphology Relate to Pain?

BACKGROUND: Individuals with clubfoot, treated in infancy with either the Ponseti method or comprehensive clubfoot release, often encounter pain as adults. Multiple studies have characterized residual deformity after Ponseti or surgical correction using physical exam, radiographs and pedobarography; however, the relationship between residual foot deformity and pain is not well defined. The purpose of the current study was 2-fold: (1) to evaluate the relationship between foot morphology and pain for young adults treated as infants for idiopathic clubfoot and (2) to describe and compare pedobarographic measures and outcome measures of pain and morphology among surgically treated, Ponseti treated, and typically developing feet. METHODS: We performed a case-control study of individuals treated for clubfoot at 2 separate institutions with either the Ponseti method or comprehensive clubfoot release between 1983 and 1987. All subjects (24 treated with comprehensive clubfoot release, 18 with Ponseti method, and 48 controls) were evaluated using the International Clubfoot Study Group (ICFSG) morphology scoring, dynamic pedobarography, and foot function index surveys. During pedobarography, we collected the subarch angle and arch index as well as the center of pressure progression (COPP) on all subjects. RESULTS: Foot morphology (ICFSG) scores were highly correlated with foot function index pain scores (r=0.43; P<0.001), although the difference in pain scores between the surgical and Ponseti group did not reach significance. The surgical group exhibited greater subarch angle and arch indexes than the Ponseti group, demonstrating a significant difference in morphology, a flatter foot. Finally, we found more abnormalities in foot progression, decreased COPP in the forefoot and increased COPP in the midfoot and hindfoot, in the surgical group compared with controls. CONCLUSIONS: Measures of foot morphology were correlated with pain among all treated for clubfoot. Compared with Ponseti method, comprehensive surgical release lead to greater long-term foot deformity, flatter feet and greater hindfoot loading time. LEVEL OF EVIDENCE: Level III-Therapeutic.

Effects of Spinal Fusion for Idiopathic Scoliosis on Lower Body Kinematics During Gait.

STUDY DESIGN: Prospective. OBJECTIVES: The purpose of this study was to compare gait among patients with scoliosis undergoing posterior spinal fusion and instrumentation (PSFI) to typically developing subjects and determine if the location of the lowest instrumented vertebra impacted results. SUMMARY OF BACKGROUND DATA: PSFI is the standard of care for correcting spine deformities, allowing the preservation of body equilibrium while maintaining as many mobile spinal segments as possible. The effect of surgery on joint motion distal to the spine must also be considered. Very few studies have addressed the effect of PSFI on activities such as walking and even fewer address how surgical choice of the lowest instrumented vertebra (LIV) influences possible motion reduction. METHODS: Individuals with scoliosis undergoing PSFI (n = 38) completed gait analysis preoperatively and at postoperative years 1 and 2 along with a control group (n = 24). Comparisons were made with the control group at each time point and between patients fused at L2 and above (L2+) versus L3 and below (L3-). RESULTS: The kinematic results of the AIS group showed some differences when compared to the Control Group, most notably decreased range of motion (ROM) in pelvic tilt and trunk lateral bending. When comparing the LIV groups, only minor differences were observed, and the results showed decreased coronal trunk and pelvis ROM at the one-year visit and decreased hip rotation ROM at the two-year visit in the L3- group. CONCLUSIONS: Patients with AIS showed decreased ROM preoperatively with further decreases postoperatively. These changes remained relatively consistent following the two-year visit, indicating that most kinematic changes occurred in the first year following surgery. Limited functional differences between the two LIV groups may be due to the lack of full ROM used during normal gait, and future work could address tasks that use greater ROM. LEVEL OF EVIDENCE: Level II.

Segmental kinematic analysis of planovalgus feet during walking in children with cerebral palsy.

Pes planovalgus (flatfoot) is a common deformity among children with cerebral palsy. The Milwaukee Foot Model (MFM), a multi-segmental kinematic foot model, which uses radiography to align the underlying bony anatomy with reflective surface markers, was used to evaluate 20 pediatric participants (30feet) with planovalgus secondary to cerebral palsy prior to surgery. Three-dimensional kinematics of the tibia, hindfoot, forefoot, and hallux segments are reported and compared to an age-matched control set of typically-developing children. Most results were consistent with known characteristics of the deformity and showed decreased plantar flexion of the forefoot relative to hindfoot, increased forefoot abduction, and decreased ranges of motion during push-off in the planovalgus group. Interestingly, while forefoot characteristics were uniformly distributed in a common direction in the transverse plane, there was marked variability of forefoot and hindfoot coronal plane and hindfoot transverse plane positioning. The key finding of these data was the radiographic indexing of the MFM was able to show flat feet in cerebral palsy do not always demonstrate more hindfoot eversion than the typically-developing hindfoot. The coronal plane kinematics of the hindfoot show cases planovalgus feet with the hindfoot in inversion, eversion, and neutral. Along with other metrics, the MFM can be a valuable tool for monitoring kinematic deformity, facilitating clinical decision making, and providing a quantitative analysis of surgical effects on the planovalgus foot.

Effect of Surgical Fusion on Volitional Weight-Shifting in Individuals With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective. OBJECTIVES: The goals of this study were to (1) evaluate the differences in weightbearing symmetry between individuals with adolescent idiopathic scoliosis (AIS) and typically developing controls; (2) observe the effect of posterior spinal fusion and instrumentation (PSFI) on volitional weight-shifting at 1 and 2 years postoperatively; and (3) evaluate whether lowest instrumented fusion level (ie, lowest instrumented vertebra [LIV]) in PSFI has an effect on volitional weight-shifting. SUMMARY OF BACKGROUND DATA: Previous studies have conflicting findings with regard to the effect of scoliosis on postural control tasks as well as the effect of surgery. They have also noted an inconsistent effect of PSFI at different LIVs, with more distal LIVs exhibiting greater reductions in postoperative range of motion. METHODS: The study was designed with an AIS group of 41 patients (8 males and 33 females) with AIS who underwent PSFI, along with a Control Group of 24 age-matched typically developing participants (12 male and 12 female). Both groups performed postural control tasks (static balance and volitional weight-shifting), with the AIS group repeating the tasks at 1 and 2 years postoperatively. RESULTS: At baseline, the AIS group showed increased weightbearing asymmetry than the Control Group (p = .01). The AIS group showed improvements in volitional weight-shifting at 2 years over baseline (p < .01). There was no effect of LIV on volitional weight-shifting by the second postoperative year. CONCLUSIONS: Individuals with AIS have greater weightbearing asymmetry but improved volitional weight-shifting over typically developing controls. PSFI improves volitional weight-shifting beyond preoperative baseline but does not differ significantly by LIV.

Response of Scoliosis in Children with Myelomeningocele to Surgical Release of Tethered Spinal Cord.

Objective: To examine the effect of surgical tethered cord release (TCR) on scoliosis in children with myelomeningocele. Methods: A retrospective review of 65 pediatric patients with myelomeningocele and TCR. The final sample consisted of 20 patients with scoliosis who were managed conservatively after TCR. Results: Average age at TCR was 6.2 years with average follow-up of 3.8 years. Scoliosis of 1 (5%) patient improved, 7 (35%) were stable, and 12 (60%) worsened (≥10°). Fifty percent of patients ultimately required definitive spinal surgery. TCR release delayed definitive spine surgery for an average of 3.2 years. Sixty-four percent of patients with curves less than or equal to 45° had progression of their curves compared to 50% with curves greater than 45°. For patients with curves less than or equal to 45°, curves progressed in 80% of those younger than 10 years as compared to 25% of those older than 10 years. For patients with curves less than or equal to 45°, 43% required definitive spine surgery as opposed to 83% with curves greater than 45°. Level of neurological involvement (ie, lumbar versus thoracic) and age at untethering emerged as factors influencing the effects of TCR for patients with curves less than or equal to 45°. Lumbar curves had more favorable results. Conclusion: Pediatric patients with myelomeningocele and scoliosis should be closely assessed and monitored. A selective approach for youth with lumbosacral level myelomeningocele and progressive curves less than or equal to 45° may result in scoliosis stabilization and avoidance of definitive surgery.

Long-term results of comprehensive clubfoot release versus the Ponseti method: which is better?

BACKGROUND: Clubfoot can be treated nonoperatively, most commonly using a Ponseti approach, or surgically, most often with a comprehensive clubfoot release. Little is known about how these approaches compare with one another at longer term, or how patients treated with these approaches differ in terms of foot function, foot biomechanics, or quality-of-life from individuals who did not have clubfoot as a child. QUESTIONS/PURPOSES: We compared (1) focused physical and radiographic examinations, (2) gait analysis, and (3) quality-of-life measures at long-term followup between groups of adult patients with clubfoot treated either with the Ponseti method of nonsurgical management or a comprehensive surgical release through a Cincinnati incision, and compared these two groups with a control group without clubfoot. METHODS: This was a case control study of individuals treated for clubfoot at two separate institutions with different methods of treatment between 1983 to 1987. One hospital used only the Ponseti method and the other mainly used a comprehensive clubfoot release. There were 42 adults (24 treated surgically, 18 treated with Ponseti method) with isolated clubfoot along with 48 healthy control subjects who agreed to participate in a detailed analysis of physical function, foot biomechanics, and quality-of-life metrics. RESULTS: Both treatment groups had diminished strength and motion compared with the control subjects on physical examination measures; however, the Ponseti group had significantly greater ankle plantar flexion ROM (p < 0.001), greater ankle plantar flexor (p = 0.031) and evertor (p = 0.012) strength, and a decreased incidence of osteoarthritis in the ankle and foot compared with the surgical group. During gait the surgical group had reduced peak ankle plantar flexion (p = 0.002), and reduced sagittal plane hindfoot (p = 0.009) and forefoot (p = 0.008) ROM during the preswing phase compared with the Ponseti group. The surgical group had the lowest overall ankle power generation during push off compared with the control subjects (p = 0.002). Outcome tools revealed elevated pain levels in the surgical group compared with the Ponseti group (p = 0.008) and lower scores for physical function and quality-of-life for both clubfoot groups compared with age-range matched control subjects (p = 0.01). CONCLUSIONS: Although individuals in each treatment group experienced pain, weakness, and reduced ROM, they were highly functional into early adulthood. As adults the Ponseti group fared better than the surgically treated group because of advantages including increased ROM observed at the physical examination and during gait, greater strength, and less arthritis. This study supports efforts to correct clubfoot with Ponseti casting and minimizing surgery to the joints, and highlights the need to improve methods that promote ROM and strength which are important for adult function. LEVEL OF EVIDENCE: Level III, prognostic study.

Effect of Lowest Instrumented Vertebra on Trunk Mobility in Patients With Adolescent Idiopathic Scoliosis Undergoing a Posterior Spinal Fusion.

STUDY DESIGN: Prospective. OBJECTIVES: The goal of this study was to evaluate the effect of posterior spinal fusion surgery terminating at different lowest instrumented vertebrae (LIV) on trunk mobility in individuals with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Posterior spinal fusion with instrumentation is the standard surgical technique employed in AIS for correcting spine deformities with Cobb angles exceeding 50°. Surgical correction of curve deformity reduces trunk mobility and range of motion. However, conflicting findings from previous studies investigating the impact of different LIV levels on the reduction in trunk mobility after surgery have been reported. METHODS: The study was designed as a prospective study with 47 patients (7 males and 40 females) with AIS who underwent posterior spinal fusion. Patients were classified into 5 groups based on their surgical LIV level (ie, T12, L1, L2, L3, and L4). Trunk flexion-extension (sagittal plane), lateral bending (coronal plane), and axial rotation (transverse plane) kinematics were assessed during preoperative, 1 year postoperative, and 2 years postoperative evaluation visits. RESULTS: There were postoperative reductions of 41%, 51%, and 59% in trunk range of motion in the sagittal, coronal, and transverse planes, respectively (p < .0001). A trend toward greater postoperative reductions in peak forward flexion at more distal LIVs was observed (p = .04). CONCLUSIONS: Fusion reduces trunk mobility in the sagittal, coronal, and transverse planes. More distal LIV fusions limit peak forward flexion to a greater extent which is considered clinically significant. After fusion, the reductions seen in axial rotation, lateral bending, and backward extension do not differ significantly at more distal LIVs.

Brace evaluation in children with diplegic cerebral palsy with a jump gait pattern.

BACKGROUND: Brace prescription for children with diplegic cerebral palsy challenges the clinician with a variety of options and little evidence for rational decisions. Previous studies have indicated that ankle-foot orthoses improve toe-walking, but it is unclear if any brace is better than another. The goal of the present study was to compare the effectiveness of hinged and dynamic ankle-foot orthoses in terms of improving gait and motor function in a homogeneous group of children with diplegic cerebral palsy exhibiting a jump gait pattern. METHODS: Fifteen children (mean age, 7.5 years) with spastic diplegic cerebral palsy who were able to walk independently with a jump gait pattern and twenty children (mean age, 10.6 years) with normal gait participated in the study. Standardized Gross Motor Function Classification System scores, Pediatric Outcomes Data Collection Instrument scores, and gait data were collected, analyzed, and compared. The subjects were tested while barefoot and while wearing hinged and dynamic ankle-foot orthoses. Data were analyzed to detect differences among these conditions. RESULTS: Significant improvements in gait metrics were seen during brace wear. No significant differences were seen between the two different braces used. The barefoot and braced conditions differed most significantly in terms of ankle kinematics and kinetics. Among the patients with cerebral palsy, no significant differences in the standardized outcome measurements were found between the braced and unbraced conditions or between the two braced conditions. CONCLUSIONS: Our data suggest that gait improves with brace wear in children with cerebral palsy with a level-I Gross Motor Function Classification System score. The Pediatric Outcomes Data Collection Instrument and the Gross Motor Function Measure were not sensitive to brace treatment in the population studied. The hinged and dynamic braces were equally effective for improving ankle kinematics and kinetics in these relatively highly functioning children with cerebral palsy.