Is recovery from ankle sprains negatively affected by obesity?

OBJECTIVE: Ankle sprains are common injuries that may lead to long-term morbidity. Individuals with obesity are at increased risk for ankle sprains; however, prognostic associations between body mass index (BMI) and recovery are less well understood. This study investigated whether BMI status affects recovery from ankle sprains. METHODS: We included individuals≥16 years old with grade 1 or 2 ankle sprains who sought emergency department treatment in Kingston, Ontario, Canada. Height in centimeters and weight in kilograms were measured at baseline by using a height rod and a standard medical column scale, respectively. BMI was calculated and categorized as non-overweight,<25.0kg/m2; overweight, 25.0-29.9kg/m2; and obese,≥30kg/m2. Recovery was assessed at 1, 3 and 6 months post-injury by the Foot and Ankle Outcome Score (FAOS). Continuous FAOS and binary recovery status were compared by BMI group at each assessment using a repeated measures linear mixed effects model and logistic regression, respectively. RESULTS: In total, 504 individuals were recruited and 6-month follow-up data were collected for 80%. We observed no significant differences in recovery at 1 and 3 months post-injury. At 6 months, between 53% and 66% of the participants were considered to have recovered according to the FAOS. The mean difference in unadjusted FAOS between participants classified as obese and non-overweight was -23.02 (95% confidence interval, -38.99 to -7.05) but decreased after adjusting for confounders. The odds ratio for recovery was 0.60 (0.37-0.97) before adjustment and 0.74 (0.43-1.29) after adjustment. Six-month recovery was significantly lower for participants with obesity than non-overweight participants on the FAOS Pain and Function in Daily Living subscales but were not clinically meaningful. CONCLUSIONS: All BMI groups showed improvements from ankle sprain over time. However, at 6 months, a sizeable proportion of the participants had not fully recovered particularly among individuals classified as obese. The findings suggest that individuals with obesity may benefit from specialized interventions focused on symptom management and functional activity.

Cost-effectiveness of continuous subcutaneous insulin infusion in people with type 2 diabetes in the Netherlands.

AIMS: Up to 30% of insulin-treated type 2 diabetes patients are unable to achieve HbA1c targets despite optimization of insulin multiple daily injections (MDI). For these patients the use of continuous subcutaneous insulin infusion (CSII) represents a useful but under-utilized alternative. The aim of the present analysis was to examine the cost-effectiveness of initiating CSII in type 2 diabetes patients failing to achieve good glycemic control on MDI in the Netherlands. METHODS: Long-term projections were made using the IMS CORE Diabetes Model. Clinical input data were sourced from the OpT2mise trial. The analysis was performed over a lifetime time horizon. The discount rates applied to future costs and clinical outcomes were 4% and 1.5% per annum, respectively. RESULTS: CSII was associated with improved quality-adjusted life expectancy compared with MDI (9.38 quality-adjusted life years [QALYs] vs 8.95 QALYs, respectively). The breakdown of costs indicated that ∼50% of costs were attributable to diabetes-related complications. Higher acquisition costs of CSII vs MDI were partially offset by the reduction in complications. The ICER was estimated at EUR 62,895 per QALY gained and EUR 60,474 per QALY gained when indirect costs were included. CONCLUSIONS: In the Netherlands, CSII represents a cost-effective option in patients with type 2 diabetes who continue to have poorly-controlled HbA1c despite optimization of MDI. Since the ICER falls below the willingness-to-pay threshold of EUR 80,000 per QALY gained, CSII is likely to represent good-value for money in the treatment of poorly-controlled T2D patients compared with MDI.

Brain control of volitional ankle tasks in people with chronic stroke and in healthy individuals.

This study explored the relationships between motor cortical control of ankle dorsiflexors and clinical impairments of volitional ankle dorsiflexion in people with chronic stroke. Eighteen persons with stroke and 14 controls were evaluated. Clinical tools were used to assess ankle dorsiflexion amplitude and isometric strength. Transcranial magnetic stimulation (TMS) of the primary motor cortex (M1) tested the functional integrity of cortical circuits controlling the tibialis anterior (TA). All clinical scores and most TMS outcomes were impaired in people with chronic stroke. The lower clinical scores were related to the reduction of the strength of corticospinal projections onto spinal motoneurons. Concurrent TMS and clinical testing in chronic stroke provided original data demonstrating relationships between the integrity of cortical and corticospinal components of TA motor control and volitional ankle tasks. Our study proposes that volitional ankle mobilization in chronic stroke may be explained by the residual abnormal M1 circuits which may be responsive for rehabilitation intervention. This should be confirmed in longitudinal studies with larger samples to determine whether TMS outcomes associated with lower limb muscles are predictive of clinical changes or vice versa.

Measuring the nursing work environment: translation and psychometric evaluation of the Essentials of Magnetism.

AIM: Translate the Essentials of Magnetism II© (EOMII; Dutch Nurses' Association, Utrecht, The Netherlands) and assess its psychometric properties in a culture different from its origin. BACKGROUND: The EOMII, developed in the USA, measures the extent to which organizations/units provide healthy, productive and satisfying work environments. As many healthcare organizations are facing difficulties in attracting and retaining staff nurses, the EOMII provides the opportunity to assess the health and effectiveness of work environments. METHODS: A three-phased (respectively N = 13, N = 74 and N = 2542) combined descriptive and correlational design was undertaken for translation and evaluation validity and psychometric qualities of the EOMII for Dutch hospitals (December 2009-January 2010). We performed forward-backward translation, face and content validation via cross-sectional survey research, and semi-structured interviews on relevance, clarity, and recognizability of instruments' items. Psychometric testing included principal component analysis using varimax rotation, item-total statistics, and reliability in terms of internal consistency (Cronbach's α) for the total scale and its subscales. RESULTS: Face validity was confirmed. Items were recognizable, relevant and clear. Confirmatory factor analysis indicated that five of eight subscales formed clear factors. Three original subscales contained two factors. Item-total correlations ranged from 0.43 to 0.83. One item correlated weakly (0.24) with its subscale. Cronbach's α for the entire scale was 0.92 and ranged from 0.58 to 0.92 for eight subscales. CONCLUSIONS: Dutch-translated EOMII (D-EOMII) demonstrated acceptable reliability and validity for assessing hospital staff nurses' work environment. IMPLICATIONS FOR NURSING AND HEALTH POLICY: The D-EOMII can be useful and effective in identifying areas in which change is needed for a hospital to pursue an excellent work environment that attracts and retains well-qualified nurses.

Rasch-built Overall Disability Scale for patients with chemotherapy-induced peripheral neuropathy (CIPN-R-ODS).

Chemotherapy-induced peripheral neuropathy (CIPN) is a common neurological side-effect of cancer treatment and may lead to declines in patients' daily functioning and quality of life. To date, there are no modern clinimetrically well-evaluated outcome measures available to assess disability in CIPN patients. The objective of the study was to develop an interval-weighted scale to capture activity limitations and participation restrictions in CIPN patients using the Rasch methodology and to determine its validity and reliability properties. A preliminary Rasch-built Overall Disability Scale (pre-R-ODS) comprising 146 items was assessed twice (interval: 2-3 weeks; test-retest reliability) in 281 CIPN patients with a stable clinical condition. The obtained data were subjected to Rasch analyses to determine whether model expectations would be met, and if necessarily, adaptations were made to obtain proper model fit (internal validity). External validity was obtained by correlating the CIPN-R-ODS with the National Cancer Institute-Common Toxicity Criteria (NCI-CTC) neuropathy scales and the Pain-Intensity Numeric-Rating-Scale (PI-NRS). The preliminary R-ODS did not meet Rasch model's expectations. Items displaying misfit statistics, disordered thresholds, item bias or local dependency were systematically removed. The final CIPN-R-ODS consisting of 28 items fulfilled all the model's expectations with proper validity and reliability, and was unidimensional. The final CIPN-R-ODS is a Rasch-built disease-specific, interval measure suitable to detect disability in CIPN patients and bypasses the shortcomings of classical test theory ordinal-based measures. Its use is recommended in future clinical trials in CIPN.

The chemotherapy-induced peripheral neuropathy outcome measures standardization study: from consensus to the first validity and reliability findings.

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating and dose-limiting complication of cancer treatment. Thus far, the impact of CIPN has not been studied in a systematic clinimetric manner. The objective of the study was to select outcome measures for CIPN evaluation and to establish their validity and reproducibility in a cross-sectional multicenter study. PATIENTS AND METHODS: After literature review and a consensus meeting among experts, face/content validity were obtained for the following selected scales: the National Cancer Institute-Common Toxicity Criteria (NCI-CTC), the Total Neuropathy Score clinical version (TNSc), the modified Inflammatory Neuropathy Cause and Treatment (INCAT) group sensory sumscore (mISS), the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, and CIPN20 quality-of-life measures. A total of 281 patients with stable CIPN were examined. Validity (correlation) and reliability studies were carried out. RESULTS: Good inter-/intra-observer scores were obtained for the TNSc, mISS, and NCI-CTC sensory/motor subscales. Test-retest values were also good for the EORTC QLQ-C30 and CIPN20. Acceptable validity scores were obtained through the correlation among the measures. CONCLUSION: Good validity and reliability scores were demonstrated for the set of selected impairment and quality-of-life outcome measures in CIPN. Future studies are planned to investigate the responsiveness aspects of these measures.

Sagittal and frontal lower limb joint moments during stair ascent and descent in young and older adults.

Stair negotiation is an essential skill required for independent mobility, and is described by older adults as a challenging task that is associated with high fall risk. Little is known about the age-related changes in joint kinetics and the relative contribution of lower limb joint moments during stair negotiation. This study characterized lower extremity joint kinetics and their variability associated with stair ascent and descent in young and older adults. Twenty three young and 32 older adults (>55 years) participated. Three dimensional, bilateral gait analysis provided ankle, knee, and hip moment profiles, which in the sagittal plane were summed to provide the support moment. In addition, intra- and inter-subject coefficients of variation were calculated for ensemble averaged curves. Age-related differences were found in the magnitudes of the moment contributions during event transitions for stair ascent and descent. Within groups, the moment profiles were generally consistent. Ankle and knee moments predominantly contributed to extensor support in the sagittal plane. In the frontal plane, proximal joint abductor moments maintained lateral stability and were larger at the hip in older adults. Understanding age-related alterations in movement control during functional tasks can help inform the rehabilitation management and assessment of patient populations.

Relationships between calf muscle density and muscle strength, mobility and bone status in the stroke survivors with subacute and chronic lower limb hemiparesis.

OBJECTIVE: To determine the relationship between muscle density and neuromusculoskeletal status in stroke survivors with subacute and chronic hemiparesis. METHODS: Community-dwelling adults were recruited into one of 3 groups (11 per group): subacute stroke group (SSG, <6 months post-stroke), chronic stroke group (CSG, >1 year post-stroke), or age- and gender-matched control group (CG). Muscle density, muscle mass and tibial bone status (cortical density, mass and polar stress-strain index (pSSI)) were measured bilaterally at the tibial 66% site using peripheral quantitative computed tomography. Muscle strength of ankle plantarflexors and knee extensors was assessed using isokinetic dynamometry. Mobility was assessed using the Berg Balance Scale. Univariate regression analyses by group tested whether side-to-side differences in muscle density and measures of neuromusculoskeletal status were related. RESULTS: In the SSG and CG, relationships were observed for muscle density and ankle plantarflexor strength (R²= 0.365 and 0.503). Muscle density related to muscle mass in the CG only (R²= 0.889). Muscle density related to cortical bone density in the SSG (R²= 0.602) and pSSI in the CSG (R²= 0.434). CONCLUSIONS: Muscle density may provide insight into the side-to-side changes in muscle and bone strength following hemiparetic stroke.

Effectiveness of a hospital-based vascular screening programme (SMART) for risk factor management in patients with established vascular disease or type 2 diabetes: a parallel-group comparative study.

AIMS: Modification of vascular risk factors is effective in reducing mortality and morbidity in patients with symptomatic atherosclerosis; however, it is difficult to achieve and maintain. The aim of the Risk management in Utrecht and Leiden Evaluation (RULE) study was to assess risk factor status after referral in patients with established vascular disease or type 2 diabetes who took part in the multidisciplinary hospital-based vascular screening programme, Second Manifestations of ARTerial disease, compared with a group who did not participate in such a programme. METHODS AND RESULTS: Patients with type 2 diabetes, coronary artery disease, cerebrovascular disease or peripheral arterial disease referred by general practitioners to the medical specialist at the University Medical Center (UMC) Utrecht (a setting with a vascular screening programme of systematic screening of risk factors followed by treatment advice) and the Leiden UMC (a setting without such a screening programme), were enrolled in the study. Blood pressure, levels of lipids, glucose and creatinine, weight, waist circumference and smoking status were measured in patients 12-18 months after referral to the two hospitals. A total of 604 patients were treated in the setting with a vascular screening programme and 566 in the setting without such a programme; 70% of all patients were male, with a mean age of 61 +/- 10 years. Amongst screened patients, systolic blood pressure [2.5 mmHg, 95% confidence interval (CI) 0.3-4.6] and the level of LDL cholesterol (0.3 mmol L(-1), 95% CI 0.2-0.4) were lower compared with the group that received usual care, after a median of 16 months from referral. CONCLUSION: Systematic screening of risk factors, followed by evidence-based, tailored treatment advice contributed to slightly better risk factor reduction in patients with established vascular disease or type 2 diabetes. However, a large proportion of patients did not reach the treatment goals according to (inter)national guidelines. Systematic screening of vascular risk factors alone is not enough for adequate risk factor management in high-risk patients.

Leisure-time physical activity and risk of type 2 diabetes in patients with established vascular disease or poorly controlled vascular risk factors.

AIM: To investigate the effect of leisure-time physical activity on the incidence of type 2 diabetes (T2DM) in patients with manifest arterial disease, or poorly controlled risk factors. METHODS: We examined 3940 patients with manifest arterial disease, hypertension or hyperlipidemia, aged 55.2+/-12.2 years. Leisure-time physical activity was measured by a questionnaire and metabolic equivalent (MET) hours per week (h/wk) were calculated. Incident T2DM was evaluated by a specific diabetes questionnaire. RESULTS: Most patients (65%) were physically inactive (0METh/wk), 12% were insufficiently physically active (0-10.5METh/wk) and 23% were sufficiently physically active (>or=10.5METh/wk). During a mean follow-up of 4.7 years, 194 (5%) incident cases of T2DM occurred. Sufficiently physically active patients had a lower incidence of diabetes (hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.37-0.83). Patients who were physically active and not-obese (BMI<30kg/m(2)) were at the lowest risk for developing T2DM (HR 0.18, 95% CI 0.12-0.28) compared with patients who were physically inactive and obese. CONCLUSIONS: Leisure-time physical activity is associated with a decreased risk of T2DM in patients with manifest arterial disease, or poorly controlled risk factors. The combination of physical activity and non-obesity is associated with an even lower risk of the development of type 2 diabetes than the sum of their independent, protective effect.

Destabilizing and stabilizing forces to assess equilibrium during everyday activities.

Postural stability is essential to functional activities. This paper presents a new model of dynamic stability which takes into account both the equilibrium associated with the body position over the base of support (destabilizing force) and the effort the subject needs to produce to keep his/her centre of mass inside the base of support (stabilizing force). The ratio between these two forces (destabilizing over stabilizing) is calculated to provide an overall index of stability for an individual. Preliminary results from data collected during walking at preferred and maximal safe speed in four older adults (aged from 64 to 84yr) showed that both forces are lower for subjects with reduced maximal gait speed. In addition, the stabilizing force increases by 2-3 times from preferred to maximal speed, while the destabilizing force barely changes with gait speed. Overall, the model through the index of stability attributes lower dynamic stability to subjects with lower maximal gait speed. These preliminary results call for larger-scale studies to pursue the development and validation of the model and its application to different functional tasks.

The occurrence of Guillain-Barre syndrome within families.

This report describes 12 Dutch families of which at least two members have had Guillain-Barre syndrome (GBS). The authors observed an earlier onset of GBS in successive generations. The occurrence of GBS within families suggests a role for genetic factors in the pathogenesis of GBS.

Women with spinal cord injury and the impact of aging.

OBJECTIVES: The objectives of this study were to describe what women with longstanding spinal cord injury (SCI) feel they are experiencing as they age, how they are coping and what they require in order to ensure their continued social and economic participation in society. STUDY DESIGN, METHODS AND SETTING: :A naturalistic approach was taken, incorporating three focus groups (n=10) and key informant interviews (n=19) of women with SCI ranging in age from 31 to 70 years and living in rural and urban communities in Ontario, Canada. RESULTS: The women feel isolated and sense many of their key concerns are ignored or dismissed by health care and service providers. The common physical changes and concerns were gynecological/sexual and bowel and bladder issues. Socio-emotional changes with age included impact of their age-related changes on important relationships and re-evaluation of personal priorities. They articulated worries including declining health, increasing dependency and financial stresses. Additional resources they need to age successfully include improved environmental accessibility, assistive devices, more flexible and responsive attendant and household support, access to recreation and fitness opportunities and peer and psychological support. CONCLUSIONS: Many of the issues raised by the women were consistent with the authors' previous examination of aging in men with SCI and women with disabilities. The most striking difference was their profound sense of isolation and perceptions that health care and service providers were unprepared or unwilling to address the unique issues they face as women living and now aging with SCI.

Asymmetry of motor cortex excitability during a simple motor task: relationships with handedness and manual performance.

Transcranial magnetic stimulation (TMS) was used to assess the relative contribution of the corticospinal (CS) pathway in activating the first dorsal interosseous (FDI) muscle in each hand of 16 right- (RH) and 16 left-handed (LH) subjects with varied degrees of hand preference. It was hypothesised that asymmetry in corticospinal activation of the two hands may be related to hand preference and interlimb differences in manual performance. Subjects performed isometric index finger abduction at force levels of 0.5 N, 1 N and 2 N while TMS was applied at resting threshold intensity (T), 0.9T, or 0.8T. The amount of contraction-induced facilitation of the muscle evoked potential (MEP) was used as an estimate of corticospinal involvement in the task. Patterns of MEP facilitation in each hand were compared with measures of manual performance (finger tapping speed, Purdue pegboard, maximal FDI strength). Threshold TMS intensities for an MEP in FDI at rest were similar in LH and RH subjects, and did not vary between hands. Facilitation of the MEP with voluntary activation was larger overall on the left side (P<0.05), but the asymmetry was dependent on the degree of lateralisation of hand preference. For subjects with consistent hand preference (either LH or RH), MEP facilitation in active FDI was larger for the left hand. For non-consistent RH subjects, contraction-induced MEP facilitation was larger in the right FDI muscle than the left. Asymmetry of MEP facilitation was not correlated with differences between hands in finger tapping speed or performance in the pegboard task, but was associated with relative differences in FDI strength. MEP facilitation tended to be larger in the stronger FDI muscle of the pair. We conclude that corticospinal involvement in the command for index finger abduction is generally greater when the left hand is used, although in RH subjects the asymmetry is influenced by the degree of lateralisation of hand preference. The corticospinal asymmetry is not related to speed or dexterity of finger movements, but the association with muscle strength suggests that it may be influenced in part by preferential use of one hand for tasks which strengthen the FDI muscle.

Tracking ability in subjects symptomatic of cumulative trauma disorder: does it relate to disability?

Symptoms of upper extremity cumulative trauma disorders (CTDs) often include weakness, discomfort, pain, numbness and stiffness, which are generally assessed clinically by using static tests or isolated movements. Little is known about the dynamic, functional ability of the upper extremity in CTD, yet, more than impairment, performance variables may relate to disability. The objectives of this study were to determine whether a manual tracking task was sensitive to the presence of symptoms associated with CTD and whether tracking performance related to disability. Forty-five volunteers who had frequently experienced one or more symptoms consistent with upper extremity CTD for at least 1 year and 22 control subjects performed the manual tracking task. Using a hand-held stylus over a digitizing tablet, subjects tracked a target that moved pseudo-randomly and was displayed on a computer screen. The root mean square error of the linear difference between target and stylus positions provided a measure of overall performance accuracy. Quadrant specific performance was also calculated to determine whether the location of the target (hence hand and wrist position) influenced performance. Additionally, the symptomatic group completed the Disability of the Arm, Shoulder and Hand (DASH) questionnaire reflecting physical disability level. Performance accuracy was poorer in symptomatic subjects than controls (p<0.001) and was influenced by target location (p<0.0001). The overall performance was associated with physical disability (r = 0.54). The findings suggest that tracking performance is sensitive to the presence of CTD symptoms and related to disability level. Further validation is required to determine whether the performance measure is sensitive to disease progression or intervention-induced changes.

Reduced interhemispheric inhibition in musicians.

In vivo magnetic resonance imaging has revealed that the anterior half of the corpus callosum is larger in musicians trained intensively from an early age than in untrained subjects. The corpus callosum is crucial for the coordination of bimanual motor activity, but neurophysiological correlates of morphological differences in the corpus callosum of musicians are not known. In the present study we have used transcranial magnetic stimulation (TMS) to assess interhemispheric inhibition in six adult professional musicians who began musical training at an early age. Conditioning TMS was applied to the hand area of the motor cortex of one hemisphere, followed 4-16 ms later by a test stimulus applied to the other hemisphere. Tests were performed at rest, and with the first dorsal interosseous muscle contralateral to the conditioning hemisphere voluntarily active. Conditioning TMS in musicians was 29% less effective at reducing the size of the test MEP at rest, and 63% less effective in the active condition, compared with control subjects. We conclude that transcallosal interhemispheric inhibitory circuits activated by TMS are less effective in musicians than in controls.

Use of visual feedback in retraining balance following acute stroke.

BACKGROUND AND PURPOSE: Visual feedback related to weight distribution and center-of-pressure positioning has been shown to be effective in increasing stance symmetry following stroke, although it is not clear whether functional balance ability also improves. This study compared the relative effectiveness of visual feedback training of center-of-gravity (CoG) positioning with conventional physical therapy following acute stroke. SUBJECTS: Forty-six people who had strokes within 80 days before the study, resulting in unilateral hemiparesis, and who were in need of balance retraining participated. METHODS AND MATERIALS: Initially, subjects were randomly assigned to visual feedback or conventional physical therapy groups for balance retraining until 16 subjects per group were recruited. The next 14 subjects were assigned to a control group. All subjects received physical therapy and occupational therapy (regular therapy) 2 hours a day, and subjects in the 2 experimental groups received additional balance training 30 minutes a day until discharge. The visual feedback group received information about their CoG position as they shifted their weight during various activities. The conventional therapy group received verbal and tactile cues to encourage symmetrical stance and weight shifting. Static (postural sway) and activity-based measures of balance (Berg Balance Scale, gait speed, and the Timed "Up & Go" Test) were contrasted across the 3 groups at baseline, at discharge, and at 1 month following discharge using an analysis of variance for repeated measures. RESULTS: All groups demonstrated marked improvement over time for all measures of balance ability, with the greatest improvements occurring in the period from baseline to discharge. No between-group differences were detected in any of the outcome measures. CONCLUSION AND DISCUSSION: Visual feedback or conventional balance training in addition to regular therapy affords no added benefit when offered in the early stages of rehabilitation following stroke.

Changes in muscle responses to stimulation of the motor cortex induced by peripheral nerve stimulation in human subjects.

The aim of this study was to determine whether prolonged, repetitive mixed nerve stimulation (duty cycle 1 s, 500 ms on-500 ms off, 10 Hz) of the ulnar nerve leads to a change in excitability of primary motor cortex in normal human subjects. Motor-evoked potentials (MEPs) generated in three intrinsic hand muscles [abductor digiti minimi (ADM), first dorsal interosseous (FDI) and abductor pollicis brevis (APB)] by focal transcranial magnetic stimulation were recorded during complete relaxation before and after a period of prolonged repetitive ulnar nerve stimulation at the wrist. Transcranial magnetic stimuli were applied at seven scalp sites separated by 1 cm: the optimal scalp site for eliciting MEPs in the target muscle (FDI), three sites medial to the optimal site and three sites lateral to the optimal stimulation site. The area of the MEPs evoked in the ulnar-(FDI, ADM) but not the median-innervated (APB) muscles was increased after prolonged ulnar nerve stimulation. Centre of gravity measures demonstrated that there was no significant difference in the distribution of cortical excitability after the peripheral stimulation. F-wave responses in the intrinsic hand muscles were not altered after prolonged ulnar nerve stimulation, suggesting that the changes in MEP areas were not the result of stimulus-induced increases in the excitability of spinal motoneurones. Control experiments employing transcranial electric stimulation provided no evidence for a spinal origin for the excitability changes. These results demonstrate that in normal human subjects the excitability of the cortical projection to hand muscles can be altered in a manner determined by the peripheral stimulus applied.

Serial casting in idiopathic toe-walkers and children with spastic cerebral palsy.

Serial casting to stretch the plantar-flexors has been advocated for idiopathic toe-walkers (ITW) and children with spastic cerebral palsy (CP), although outcomes have not been well studied. Neuromuscular function and gait were examined in eight children with CP (mean age, 7.1 years) and eight ITW (mean age, 7.5 years) casted for 3 to 6 weeks. Baseline comparisons indicated that children with CP produced lower isometric plantar-flexor torques (p<0.02) concomitant with marked co-contraction (p<0.001). greater ankle mobility (p<0.02), and higher reflex excitability (p<0.001) than ITW. After casting, both groups increased dorsiflexion range (p<0.001), decreased resistance to passive stretch (p<0.005), and produced maximal plantar-flexor torques in dorsiflexed positions (p<0.001). Reflex excitability was reduced in CP (p<0.05). Immediately postcasting, no children toe-walked, but two with CP resumed a digitigrade pattern 6 weeks later. Gait velocity and stride length did not change (p>0.05). Serial casting yielded positive outcomes that may be longer lasting in ITW.