Effects of solid ankle-foot orthoses with individualized ankle angles on gait for children with cerebral palsy and equinus.

PURPOSE: For children with cerebral palsy (CP) and equinus, the conventional practice of setting the ankle angle in an ankle-foot orthosis (AA-AFO) at 90∘ may not adequately accommodate gastrocnemius length/stiffness. Therefore, this study compared the effects of statically-optimized solid AFOs with individualized AA-AFOs (iAA-AFOs) and conventionally-prescribed AFOs on gait for children with CP and equinus. METHODS: Ten children with CP and equinus (15 limbs with AFOs), and 15 typically-developing (TD) children participated. For the children with CP, solid AFOs with iAA-AFOs (range = 5∘-25∘ plantarflexion) were compared with their usual AFOs using three-dimensional gait analysis. TD children walked in shoes only. Peak values and Gait Variable Scores (GVS) for joint and segment variables were calculated for stance phase. Responses were categorized using 90% confidence intervals relative to TD data, for each affected leg. RESULTS: Net responses to iAA-AFOs were positive for 60% of limbs and negative for 40%. Knee variables (GVS and peak extension, flexion, and midstance moment) were most positively affected, and foot-floor angle and vertical ground reaction force were most negatively impacted. CONCLUSION: Individualized AFO prescription and iAA-AFOs can impact gait biomechanics for some children with equinus, compared to conventionally-prescribed AFOs. Optimizing dynamic alignment for walking may further improve outcomes.

Comparison of the effect of focused and radial extracorporeal shock waves on spastic equinus in patients with stroke: a randomized controlled trial.

BACKGROUND: Recent studies have suggested that either focused or radial shock wave therapy is an effect method for the treatment of spasticity in patients with stroke. However, no previous study compared these two types of extracorporeal shock wave on spasticity in patients with stroke. This study aimed to compare the effect of focused and radial shock wave therapy for the treatment of spastic equinus in patients with stroke. DESIGN: Randomized control trial. SETTING: Outpatient rehabilitation center in a medical center. POPULATION: Thirty-two stroke patients with spastic equinus (18 males and 14 women; mean age, 60.1±10.6 years). METHODS: Patients were randomly assigned to receive three sessions of either focused or radial shock wave therapy at 1-week intervals. The intensities that were used during focused shock wave therapy (0.12 mJ/mm2) and radial shock wave therapy (2.4 bar) were comparable. The patients were evaluated at baseline and at 1, 4, and 8 weeks after the final shockwave treatment. The primary outcome measure was change of modified Ashworth Scale Score of gastrocnemius muscle. The secondary outcome measures were Tardieu Scale, ankle passive range of motion, dynamic foot contact area and gait speed. A linear mixed model with repeated measures was used to compare each outcome measure between the two groups. RESULTS: Both groups improved significantly in terms of modified Ashworth Scale Score and Tardieu Scale, and no differences were found between the two groups. In terms of ankle passive range of motion and plantar contact area during gait, the radial shock wave therapy yielded a significantly greater improvement than the focused shock wave therapy. No significant changes were observed in gait speed in either group. CONCLUSIONS: Our study suggested that focused and radial shock wave therapy resulted in similar significant improvements in the modified Ashworth scale score and Tardieu scale, but those in the radial shock wave therapy group experienced greater improvements in the ankle passive range of motion and plantar contact area during gait. CLINICAL REHABILITATION IMPACT: Both focused and radial shock wave therapy yielded similar improve the spasticity of gastrocnemius muscle. Radial shock wave therapy is superior to focused shock wave therapy in terms of improving the ankle passive range of motion and plantar contact area during gait in patients with stroke.

Dynamic pedobarographic classification of idiopathic toe-walkers for therapeutical indication / Clasificación baropodométrica dinámica de los andadores de puntillas para la indicación terapéutica

Idiopathic toe-walkers (ITWs) pedobarographic analysis has not been described yet nor its possible relationship with orthopedical and developmental characteristics. The objective of this research is to develop a dynamic pedobarographic classification of ITWs to propose a specific therapeutical approach. Through an observational study, 56 ITWs aged 3-6 years were classified by their initial foot contact; differences between idiopatic toe-walking (ITW) types and with respect to 40 control children were calculated by means of ANOVA and Student t-tests. The results show that the three ITW types displayed different step models for pressure and impulse distribution and also for temporal development (p<.05). They also showed different orthopedic and developmental characteristics (p<.05). As a whole, they demonstrated different severity levels, which suggest different therapeutical indications. This study confirms the convenience of a specific orthopedic, developmental, and gait assessment in ITW to clarify therapeutical indication

El análisis baropodométrico de la marcha de los andadores de puntillas (AP) no ha sido aún descrito en la literatura, ni tampoco su posible relación con sus características ortopédicas y neuromadurativas. El objetivo de este trabajo es desarrollar una clasificación baropodométrica dinámica de los AP para proponer un abordaje terapéutico específico. En un estudio observacional, 56 AP de 3 a 6 años han sido clasificados por su contacto inicial del pie, calculándose las diferencias entre los diferentes tipos de AP y con respecto a 40 niños que conformaron el grupo control, mediante los tests ANOVA y t de Student. Los resultados demostraron que los tres tipos de AP tenían diferentes modelos de paso en cuanto a la distribución de presiones e impulsos y también en su desarrollo temporal (p<.05). También se encontraron diferencias significativas en sus características ortopédicas y neuromadurativas (p<.05). En conjunto, los tres grupos de AP demostraron diferentes niveles de severidad que sugieren la indicación de abordajes terapéuticos diversos. Este estudio confirma la necesidad de una valoración específica de la marcha ortopédica y neuromadurativa en los AP para clarificar la indicación terapéutica

A Critical Evaluation of the Updated Evidence for Casting for Equinus Deformity in Children with Cerebral Palsy.

BACKGROUND AND PURPOSE: Equinus deformity is common in ambulant children with cerebral palsy (CP). Although lower leg casting is frequently used, the physiological basis for casting and effects beyond range of motion (ROM) gains are unclear. This review critically evaluates the updated evidence for casting in the management of ankle equinus in children with CP. METHODS: Comprehensive searches were conducted using electronic databases AMED, MEDLINE, CINAHL, Scopus, PEDro and the Cochrane Database of Systematic Reviews, publication years 2005-2014, in order to identify literature published since an earlier comprehensive systematic review. Only studies evaluating lower leg casting for conservative management of equinus deformity in children with CP were considered. Two independent raters critically appraised studies against the hierarchy of levels of evidence and rigour of study conduct questions proposed by the American Academy of Cerebral Palsy and Developmental Medicine's methodology for systematic review. RESULTS: Four relevant systematic reviews were identified, although these largely concerned earlier literature. Five original studies were included, all demonstrating improvement in dorsiflexion ROM. Combined treatment with botulinum toxin and casting offered greater and/or more sustained ROM gains than botulinum toxin alone in three studies. Effects on gait parameters and motor function were inconsistent. Participation outcomes were not evaluated. Methodological limitations make firm conclusions difficult. CONCLUSIONS: Recent years have offered little progress in the state of evidence for casting in the management of equinus deformity. Casting appears to offer at least short-term improvement in ankle dorsiflexion, although the proposition that this improves function or avoids surgery is not well substantiated. Future research needs to ensure more robust study design and broader evaluation across domains of the International Classification of Functioning, Disability and Health to determine the functional and long-term effect of casting for equinus deformity. Greater knowledge is required of the effect of casting on muscle structure and function in spastic CP. Copyright © 2015 John Wiley & Sons, Ltd.

Real-time feedback of dynamic foot pressure index for gait training of toe-walking children with spastic diplegia.

PURPOSE: The aim of this study was to determine whether and how real-time feedback of dynamic foot pressure index (DFPI) could be used to correct toe-walking gait in spastic diplegic children with dynamic equinus. METHODS: Thirteen spastic diplegic children with dynamic equinus were asked to wear a monitoring device to record their ambulation during daily gait, conventional training gait, and feedback training gait. Parameters based on their DFPI and stride duration were compared among the three test conditions. RESULTS: The results with feedback training were significantly better for all DFPI parameters in comparison to patients' daily gait and showed significant improvements in DFPI for toe-walking gait and percentage of normal gait in comparison to conventional training methods. Moreover, stride duration under two training gaits was longer than patient's daily gait, but there was no significant difference between the two training gaits. CONCLUSIONS: Although the stride duration for the two training gaits was similar, gait training with real-time feedback of DFPI did produce noticeably superior results by increasing heel-loading impulse of toe-walking gait and percentage of normal gait in comparison to convention training methods. However, its effectiveness was still impacted by the motion limitations of diplegic children. Implications for Rehabilitation The DFPI-based gait training feedback system introduced in this study was shown to be more effective at toe-walking gait rehabilitation training over conventional training methods. The feedback system accomplished superior improvement in correcting toe-walking gait, but its effectiveness in an increasing heel-loading impulse in normal gait was still limited by the motion limitations of diplegic children. Stride duration of normal gait and toe-walking gait was similar under conventional and feedback gait training.

Randomized Controlled Trial on Effectiveness of Intermittent Serial Casting on Spastic Equinus Foot in Children with Cerebral Palsy After Botulinum Toxin-A Treatment.

OBJECTIVE: Physical therapy (PT) and botulinum toxin-A (BTX-A) injections are widely used in the treatment of spastic equinus foot due to cerebral palsy. The aim of this study was to show effects of intermittent serial casting (SC) in addition to standard treatment on spasticity, passive range of motion (PROM), and gait. DESIGN: Fifty-one ambulatory patients, treated by BTX-A to plantar flexor muscles, were randomly assigned to casting or control groups in a 2:1 ratio. Both groups received PT for 3 weeks. Casting group additionally received intermittent SC during 3 consecutive weekends. Assessments included Modified Ashworth Scale (MAS), Tardieu Scale, Observational Gait Scale (OGS), and Physician Global Assessment at baseline and posttreatment weeks 4 and 12. RESULTS: Significant improvements in PROM, MAS, Tardieu Scale, and OGS were recorded in both groups (P < 0.001 for all). Average changes in MAS, PROM, angle of catch, spasticity angle, and OGS of the casting group were significantly higher than those of the controls at week 4 (P = 0.006, P = 0.002, P < 0.001, P = 0.005, P = 0.011), and 12 (P = 0.013, P < 0.001, P < 0.001, P = 0.011, P < 0.001). Follow-up Physician Global Assessment also favored casting group (P < 0.001 for both). CONCLUSIONS: Combining intermittent SC with BTX-A injections and PT might provide additional benefits for spastic equinus foot. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) identify treatment options for spastic equinus goot in children with cerebral palsy; (2) explain different approaches of serial casting with an additional model of intermittent casting; and (3) describe the potential benefits of combined treatment modalities, including intermittent serial casting, for spastic equinus foot in children with cerebral palsy. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Efectos a medio y largo plazo sobre la marcha de un programa de ejercicio domiciliario y ortesis de uso nocturno en niños con equinismo idiopático / Medium and long-term effects on gait cycle of home-based exercise program and use of a night splint in children with idiopathic toe walking

Introducción: El equinismo idiopático es una alteración de la marcha pediátrica caracterizada por la realización de una excesiva flexión plantar del tobillo durante la marcha. No hay consenso en la literatura acerca de la mejor oferta terapéutica, coexistiendo opciones conservadoras y quirúrgicas en la práctica clínica. El objetivo de este trabajo es comprobar el impacto de un programa de ejercicios domiciliarios asociado al uso de una ortesis nocturna en el manejo del niño con equinismo idiopático. Material y métodos: Se realizó un estudio cinemático comparativo a los 6, 12 y 18 meses de 29 niños con equinismo idiopático, comparando los datos con los de 15 niños con marcha normal. La propuesta de tratamiento consistió en ejercicios domiciliarios asociados a una ortesis de uso nocturno durante 12 meses. Resultados: La propuesta terapéutica planteada ofrece normalización de los parámetros cinemáticos a los 18 meses de evolución. Se encontraron cambios estadísticamente significativos en los valores cinemáticos de la marcha estudiados (A1, A3, A5 y GDI), así como en una de las variables de la exploración física (rango de dorsiflexión). Todos los cambios se produjeron en dirección a los valores cinemáticos durante la marcha del grupo de niños sin patología. Conclusiones: El análisis del movimiento es una herramienta de monitorización de los trastornos de la marcha y control de evolución para los niños con equinismo idiopático. El ejercicio domiciliario asociado a una ortesis nocturna ofrece resultados positivos en la corrección de la marcha en niños con equinismo idiopático (AU)

Introduction: Idiopathic toe walking (ITW) is a common paediatric gait disorder characterised by excessive plantar flexion during the gait cycle. There is no consensus in the literature about the best therapeutic approach to treat ITW and different conservative and surgical options are used in clinical practice. The main objective of this study is to evaluate the clinical impact of a home-based exercise program associated with the use of a night splint (AFO) for managing gait problems in children with ITW. Material and methods: This is a comparative kinematic study. Long-term follow-ups were conducted at 6, 12, and 18 months with 29 children with ITW and 15 healthy children. The proposed treatment was a home-based exercise associated with a night splint for 12 months. Results: The therapeutic approach improved several kinematic values by the 18-month follow-up. We found statistically significant differences for gait kinematics (A1, A3, A5 and GDI) and one of the clinical examination variables (ankle passive dorsiflexion). All the differences showed a normalization of gait kinematics, with critical kinematic values close to the normalcy data. Conclusions: 3D gait analysis is an assessment tool for gait disorders and for long-term follow-up of children with ITW. Our home-based exercise associated with a night splint showed good results for gait disorders treatment in children with idiopathic toe walking (AU)

Is there still a place for Achilles tendon lengthening?

Patients with diabetes and ankle equinus are at particularly high risk for forefoot ulceration because of the development of high forefoot pressures. Stiffness in the triceps surae muscles and tendons are thought to be largely responsible for equinus in patients with diabetes and underpins the surgical rationale for Achilles tendon lengthening (ATL) procedures to alleviate this deformity and reduce ulcer risk. The established/traditional surgical approach is the triple hemisection along the length of the Achilles tendon. Although the percutaneous approach has been successful in achieving increases in ankle dorsiflexion >30°, the tendon rupture risk has led to some surgeons looking at alternative approaches. The gastrocnemius aponeurosis may be considered as an alternative because of the Achilles tendon's poor blood supply. ATL procedures are a balance between achieving adequate tendon lengthening and minimizing tendon rupture risk during or after surgery. After ATL surgery, the first 7 days should involve reduced loading and protected range of motion to avoid rupture, after which gradual reintroduction to loading should be encouraged to increase tendon strength. In summary, there is a moderate level of evidence to support surgical intervention for ankle joint equinus in patients with diabetes and forefoot ulceration that is non-responsive to other conservative treatments. Areas of caution for ATL procedures include the risk for overcorrection, tendon rupture and the tendon's poor blood supply. Further prospective randomized control trials are required to confirm the benefits of ATL procedures over conservative care and the most optimal anatomical sites for surgical intervention.

Ortesis pasiva tobillo-pie de uso nocturno en la prevención del pie equino en la parálisis cerebral / Nocturnal use of an ankle-foot orthosis in the prevention of equinuus in cerebral palsy

Introducción. El equinismo, que es la deformidad más frecuente en los pacientes con parálisis cerebral, aumenta la inestabilidad, dificulta la marcha y la adaptación a la silla de ruedas. La corrección del equinismo beneficia al niño deambulador, facilita la adecuada colocación del pie en el reposapiés de la silla de ruedas y la posibilidad de usar un calzado convencional en el niño que no tiene capacidad de marcha. El objetivo de este estudio es valorar si el uso nocturno de ortesis de tobillo-pie en ortoposición permite prevenir o diferir la aparición de equinismo y así evitar o retrasar la cirugía de alargamiento tendinoso. Material y método. Se ha realizado un estudio observacional descriptivo retrospectivo, revisando el historial clínico de pacientes diagnosticados de parálisis cerebral, tratados mediante ortesis de tobillo-pie nocturnas en la Unidad de Rehabilitación Infantil del Hospital Virgen Macarena. Resultados. De los 90 pacientes tratados con la ortesis de tobillo-pie nocturna, el 88,9% consiguió el rango de flexión dorsal necesario para la deambulación (≥ 10°) o la correcta adaptación a la silla de ruedas y al calzado (≥ 0°). Únicamente en 9 pacientes (10% de los casos) no se alcanzaron los objetivos pretendidos. Conclusión. El tratamiento preventivo con ortesis rígidas constituye una opción de primera línea en el tratamiento de la parálisis cerebral. El uso reglado y mantenido de las ortesis de tobillo-pie nocturnas puede retrasar la aparición del equinismo en la parálisis cerebral y permite diferir o evitar la cirugía con un beneficio funcional evidente (AU)

Introduction. Equinus, the most common deformity in patients with cerebral palsy, increases instability and impairs gait and adaptation to a wheelchair. Correction of equinus benefits walking children and aids proper placement of the foot on the footrest of a wheelchair. It also allows the possibility of using conventional footwear in children with no ability to walk. The aim of this study was to assess whether the use of an ankle-foot orthosis at night, keeping the foot in orthoposition, can prevent or delay the onset of equinus and thus prevent or delay tendon lengthening surgery. Material and methods. We performed a retrospective observational study based on a chart review of 90 patients diagnosed with cerebral palsy treated with a nocturnal ankle-foot orthosis in the Children's Rehabilitation Unit at Hospital Virgen Macarena in Spain. Results. Of the 90 patients treated with nocturnal ankle-foot orthosis, 88.9% achieved the dorsiflexion necessary for ambulation (≥ 10°) or adequate adaptation to a wheelchair and footwear (≥ 0°). Only 9 patients (10%) did not achieve the intended objectives with the use of the splint. Conclusion. Preventive treatment with a rigid ankle-foot orthosis is a widely accepted practice that constitutes a first-line option in the treatment of cerebral palsy. Systematic and persistent use of a nocturnal ankle-foot orthosis can delay the onset of equinus in cerebral palsy and can delay or avoid surgery, with a clear functional benefit (AU)

Technique, indications, and results of proximal medial gastrocnemius lengthening.

Gastrocnemius proximal lengthening was first performed to correct spasticity in children, and was adapted for the patient with no neuromuscular condition in the late 1990s. Since then, the proximal gastrocnemius release has become less invasive and has evolved to include only the fascia overlying the medial head of the gastrocnemius muscle. The indications for performing this procedure are a clinically demonstrable gastrocnemius contracture that influences a variety of clinical conditions in the forefoot, hindfoot, and ankle. It is a safe and easy procedure that can be performed bilaterally simultaneously, and does not require immobilization of the ankle after surgery.

Effects of a dynamic-ankle-foot orthosis (Liberté®) on kinematics and electromyographic activity during gait in hemiplegic patients with spastic foot equinus.

BACKGROUND: A dynamic-ankle-foot orthosis has recently emerged and consists of an elastic band allowing the variation of stiffness degree and adjusts dorsiflexion assistance in swing. The aim of this study was to quantify the biomechanical adaptations induced by this orthosis during gait in hemiplegic patients. METHODS: Twelve hemiplegic patients performed two gait analyses (without and with the ankle-foot orthosis). Spatiotemporal, kinematic, kinetic and electromyographic gait parameters were quantified using an instrumented gait analysis system during the stance and swing phases. RESULTS: During swing, peak ankle dorsiflexion was greater with the orthosis and associated with a decrease of pelvic obliquity angle. In stance, peak ankle plantarflexion and dorsiflexion were greater with the orthosis and associated with an increase of ankle angle at heel strike and toe-off. Electromyographic activities of both the tibialis anterior and the medial gastrocnemius were greater with the orthosis. CONCLUSIONS: This dynamic-ankle-foot orthosis improved gait in hemiplegic patients with spastic foot equinus. The spatiotemporal adaptations seem to be caused mainly by the increase of ankle dorsiflexion during stance and swing phases. The changes in electromyographic activity were related to an active dorsiflexion in stance and swing phases and an active plantarflexion in stance phase.

Biofeedback baropodometry training evaluation: a study with children with equinus foot deformity.

The lack of perception in the hindfoot increases the plantar flexion, causing irregular posture due to the foot position, a disability known as equinus foot deformity. A portable device, named baropodometer, that measures the pressure at the forefoot and hindfoot regions was built to help this population in terms of balance and posture correction. Ten hemiparetic teenager volunteers with equinus foot participated in the experiments. The results demonstrated that the proposed device increased the weight-bearing in upright stance in the paretic side, decreasing the weight in the non-paretic side. After 10 experimental sessions, performed along 6 months, the distribution of the pressure in the lower limbs was very similar. The baropodometer facilitates the rehabilitation, by biofeedbacking the pressure of the calcaneus, using the volunteer's audiovisual system. The rehabilitation using the proposed device was able to recover the balance by posture correction, facilitating future gait training of these volunteers.

Desarrollo locomotor en pacientes con displasia del desarrollo de cadera y pie equino varo congénito que recibieron tratamiento ortopédico antes del año de vida. Estudio prospectivo comparativo / Locomotor development in infants with developmental dysplasia of the hip or idiopathic clubfoot undergoing orthopedic treatment. Prospective comparative study

Objetivos: Diversas afecciones de presentación temprana en la niñez, como la displasia del desarrollo de la cadera (DDC) y el pie equino varo congénito (PEVAC), requieren de tratamiento ortopédico, limitando la movilidad activa de las extremidades inferiores por un período prolongado. El objetivo es evaluar el impacto sobre el desarrollo locomotor del tratamiento ortopédico en niños menores de un año de vida. Pacientes y métodos: Se analizó una cohorte prospectiva de pacientes consecutivos con diagnostico de DDC (24 pacientes) y PEVAC (32 pacientes), tratados de manera ortopédica entre enero del 2007 y junio del 2009. Se utilizó como control un tercer grupo de 50 niños sanos. Se evaluaron el tiempo con ortesis y la edad al sentado, gateo y al comienzo de la marcha. Las comparaciones entre los 3 grupos fueron realizadas con una prueba de Kruskal-Wallis y entre sí con una prueba de U de Mann-Whitney. Un valor de p < 0,05 fue considerado como significativo. Resultados: El análisis de muestras independientes mostró que las medias de las edades en meses para sentarse entre los 3 grupos (control, DDC y PEVAC), 6,12, 6,42 y 6,19, respectivamente, fueron similares (p = 0,249). Las medias para gatear, 8,84, 9,38 y 9,17, fueron similares, aunque con una discreta tendencia a la significación estadística (p = 0,08). Las medias para el inicio de la marcha, 12,14, 13,21 y 12,41, fueron distintas entre los 3 grupos (p < 0,001). Conclusión: El tratamiento ortopédico de la DDC y el PEVAC en niños menores de un año retrasa levemente el desarrollo locomotor normal (AU)

Objectives: Several disorders of early childhood, such as developmental dysplasia of the hip (DDH) and clubfoot, requires orthopedic treatment that limits active mobility of the lower extremities for a period of time. The aim of our study was to evaluate the impact on locomotor development of the orthopedic treatment in infants less than one year-old. Patients and methods: The study included a prospective cohort of consecutive patients diagnosed with developmental dysplasia of the hip (Group A, 24 patients), and clubfoot (Group B,32 patients) treated from January 2007 to June 2009. A third group (Group C) of 50 healthy children was used as control. The variables evaluated were: months with a brace, age to sit withoutsupport, age at the start of crawling, and age at the beginning of walking. The results obtainedwere analyzed. Comparisons between the three groups were performed using the Kruskal-Wallis test and Mann-Whitney test. We chose a value of P<0.05 as level of statistical significance. Results: The analysis of independent samples showed that the mean age at which the patients began to sit were similar: 6.12, 6.42 and 6.19 months, respectively (P=0.249). The mean age for crawling was similar, although with a slight trend toward statistical significance: 8.84, 9.38 and 9.17 months, respectively (P=.08). The age at which they started walking was different between the three groups: 12.14, 13.21 and 12.41 months, respectively (P<0.001). Conclusion: Orthopedic treatment of DDH and clubfoot in children less than one year-old slightly slows down the course of normal locomotor development (AU)

Equinus foot classification in cerebral palsy: an agreement study between clinical and gait analysis assessment.

BACKGROUND: Excessive ankle plantar flexion (equinus foot) is a common problem in cerebral palsy (CP) and several treatment options can be considered depending on the equinus type. Few attempts have been made to classify different forms of equinus foot for specific treatment. AIM: This study is aimed at defining equinus foot types in CP patients according to the Ferrari classification, integrating clinical and instrumental assessments. The hypothesis is that clinical differentiation of equinus foot can be evidenced by recurrent anomalies identifiable through gait analysis (GA), which can make the assessment, usually based only on clinician semeiotics, more objective. DESIGN: Clinical and instrumental assessments were performed separately by a senior CP physiatrist and a senior GA physiatrist, the latter was blind to the clinical diagnosis of equinus type. SETTING: Outpatients POPULATION: Twenty patients, 16 diplegics and 4 hemiplegics (mean age 11 years, SD 4 years 11 months). METHODS: Clinical assessment by means of Modified Ashworth Scale, Gross Motor Function Measure (GMFM), Observational Gait Analysis (OGA), and measurement of lower limb muscle strength by dynamometer were used to classify the equinus type. Gait analysis assessed the kinematics and EMG of affected lower limbs. RESULTS: Ten different equinus types were identified. Since various forms of equinus can be present in the same patient, we were able to classify a total of 61 types of equinus in 36 feet. Substantial agreement was found between Clinical and Gait Analysis equinus assignment matched in 50 out of 61 types (Index of agreement with Fleiss' Kappa 79.3 % ). In some case only Gait Analysis was able to identify the equinus type, while in others it did not confirm clinical assignment. CONCLUSION: Gait analysis is able to distinguish different equinus types according to Ferrari classification, making the clinical decision less arbitrary. CLINICAL REHABILITATION IMPACT: Correct objective diagnosis of equinus foot in CP patients is of paramount importance when choosing suitable rehabilitative interventions.

Pilot studies suggesting new applications of NiTi in dynamic orthoses for the ankle joint.

NiTi is a metal alloy with unconventional functional characteristics: Shape memory and pseudoelasticity. Its use in the field of rehabilitation is very innovative. This work presents applications in lower limb orthotics. Three different devices were assembled and tested: An equinus gait dynamic splint, a compliant ankle positioning brace, and a dual-mode haptic/active exerciser for the dorsiflexors. Results are derived from technical and preclinical trials. The gait splint improves several walking parameters even better than a traditional flexible ankle-foot orthoses (AFO). In particular, it supports mid-stance and propulsion biomechanics and affects physiological activation of tibialis anterior during swing much less than posterior leaf AFO. The haptic/active exerciser, able to provide dorsiflexion through a suitable articular range, could be controlled on the basis of minimal surface electromyographic (sEMG) signals, suggesting its use as an aid for early active workouts as soon as patients start to recover voluntary control of tibialis anterior. Further evidence must be sought in future to confirm for the ankle joint the promising results obtained in repositioning applications in prior upper limb studies. The work done so far on the tested prototypes is encouraging: Material characteristics and dimensioning will be optimized so that customized NiTi devices can be prescribed to best meet individual patients' requirements.

Compartment syndrome after serial casting in spastic diplegic cerebral palsy: a case report.

We present the case of a 24-year-old woman with spastic diplegic cerebral palsy who developed left lower extremity compartment syndrome after serial casting to treat an equinus contracture. To our knowledge, this represents the first case of compartment syndrome that has occurred from cast application to treat a deformity. The cast was the second placed in the treatment series and was removed 18 hours later because of increased pain. The clinical picture progressed despite the cast being removed. Accordingly, the patient presented to the emergency department with uncontrollable pain and a peroneal nerve deficit. Compartment pressures were measured in the anterior, lateral, superficial, and deep posterior compartments and were 80, 56, 31, and 90 mmHg, respectively. She required 4-compartment fasciotomy, eventual skin grafting of her lateral wound, and late gastrocnemius lengthening for recurrent equinus contracture. The purpose of this report is to alert clinicians to the potential for compartment syndrome to occur as a result of serial casting applied to correct deformity.

Improvement of gait in a stroke patient. A 7-year longitudinal study.

PURPOSE: To report on the gait improvement obtained in a stroke patient after applying three treatments for spastic equinus varus foot: botulinum toxin injection (BTI), tibial nerve neurotomy (TNN), and orthopaedic surgery (triple arthrodesis), during a 7-year longitudinal follow-up period. METHOD: A quantified analysis of a stroke patient's gait was performed on a Gaitrite walking mat before and after applying BTI 3 years, TNN 4 years and orthopaedic surgery 7 years after the stroke. RESULTS: After the three treatments, the spasticity disappeared, the range of ankle motion improved and voluntary command of the tibialis anterior became possible. Upon comparing the gait parameters before treatment and after the three treatments, it was observed that the comfortable gait velocity had increased (from 0.42 m/s to 0.70 m/s), the step length had become more symmetrical (from left 19 cm, right 57 cm to left 50 cm, right 51 cm), the step width had decreased (from 23 cm to 12 cm). In terms of participation, walking barefoot had become possible without a cane, as well as going up and down stairs and walking outdoors on uneven ground without any help. CONCLUSIONS: Stroke patients during the chronic phase with a spastic equinovarus deformity can benefit from various commonly used therapeutic interventions. BTI and TNN were found to be efficient but only for a short time. Orthopaedic surgery gave the most long-lasting results. Further studies should be performed on a larger number of patients to determine the most suitable options for treating stroke patients with an equinus varus foot.

[Repetitive peripheral magnetic stimulation. Treatment option for spasticity?]. / Repetitive periphere Magnetstimulation. Therapieoption bei Spastik?

BACKGROUND: In an open study the effect of repetitive peripheral magnetic stimulation (RPMS) on the spastic talipes equinus of various origins, degree and duration was evaluated in 53 children and adolescents. STUDY DESIGN AND METHODS: Clinical and electrophysiological investigations were designed to measure the RMPS effect on the spasticity and the functional capabilities of the spastic talipes equines. Moreover, the duration of the effect of one RPMS session should be established. The magnetic stimulation comprising 10 series of 10 s duration was applied over the first sacral radix using a frequency of 20 Hz and a 1.2-fold intensity above the motoric threshold. RESULTS: The RPMS significantly reduced the tonus of the spastic talipes equines and this effect lasted for 1 week. No significant changes of electrophysiological parameters measuring the F-wave, H-reflex und ASR tendon reflex could be observed. CONCLUSION: The RPMS could prove to be an effective option for the treatment of spasticity. However, this method needs further evaluation by evidence-based studies.

Botulinum toxin type A injections into the calf muscles for treatment of spastic equinus in cerebral palsy: a randomized trial comparing single and multiple injection sites.

OBJECTIVE: To investigate the hypothesis that the multiple-site injection technique is associated with better outcomes than the single-point injection method in children with cerebral palsy and spastic equinus gait. DESIGN: A total of 17 children (nine boys, eight girls ages 1.8-9.4 yrs; eight hemiplegics, eight diplegics, one quadriplegic; levels I-IV with the Gross Motor Function Classification System) with 25 treated lower limbs were randomized into two groups: a single-point group receiving a standard dose of botulinum toxin A injection into one site and a multiple-points group into two sites on both heads of the gastrocnemius. Active and passive range of movement, selective dorsiflexion, dynamic muscle length (modified Tardieu scale), calf tone (modified Ashworth scale), attainment of anticipated gait pattern (Goal Attainment Scale), and video gait analysis (Observational Gait Scale [OGS]) were assessed before and 1, 2, and 4 mos after intervention. RESULTS: Both groups improved in dynamic muscle length, muscle tone, OGS-total scores and initial foot contact scores and a similar number of children attained their goals on the Goal Attainment Scale. The only significant difference between the groups was observed at 2 mos in passive dorsiflexion with the knee flexed, favoring the single-point group. Though not significantly, the incidence of adverse effects was higher in the multiple-points group. CONCLUSIONS: Using the methods described, no major changes in main outcome measures were associated with the number of injection sites. Issues other than efficacy guide the decision on whether to inject in single or multiple sites when treating spastic equinus with botulinum toxin.

Gait recovery in a distal spinal muscular atrophy patient wearing a patellar tendon-bearing orthosis and orthopaedic shoes.

OBJECTIVE: To illustrate that a patient with distal spinal muscular atrophy can recover gait with a combination of orthoses and orthopaedic shoes. SUBJECT: A 28-year-old man with distal spinal muscular atrophy affecting only the distal muscles of the lower limbs. Clinical examination showed a bilateral pes cavus with a varus and a 90 degrees equinus of the ankle joint. METHODS: The patient was fitted with orthopaedic shoes and a patellar tendon-bearing orthosis. In order to assess the clinical effects of this fitting, a complete physical examination was performed and the patient's temporo-spatial gait parameters were assessed quantitatively using gait analysis tools (Gaitrite) both prior to treatment and after one month. RESULTS: Before the fitting, the patient was not able to walk alone or to maintain an upright position and he suffered from foot pain. One month after the fitting was applied, the patient was able to walk alone and to maintain an upright position for 1 hour. His pain disappeared. Quantified study of the patient's gait parameters shows that the temporo-spatial parameters are close to normal with fitting. CONCLUSION: Clinical and quantitative data both confirm the subjective improvements reported by the patient.