The functional effect of segmental trunk and head control training in moderate-to-severe cerebral palsy: A randomized controlled trial.

PURPOSE: To determine whether segmental training is more effective in improving gross motor function in children and young people with moderate-to-severe cerebral palsy than conventional physiotherapy. METHODS: Twenty-eight participants were randomized to a segmental training or control group. Outcomes were Gross Motor Function Measure (GMFM), Pediatric Evaluation of Disability Inventory (PEDI), Segmental Assessment of Trunk Control (SATCo), and postural sway at baseline, at primary endpoint (6 months), and at follow-up (12 months). RESULTS: There were no significant differences in either GMFM, PEDI, or SATCo scores at primary endpoint or follow-up. There were significant reductions in anterior-posterior head angular sway and trunk sway in the segmental training group at primary endpoint but not at follow-up. CONCLUSION: Segmental training was not superior to usual care in improving GMFM. Improvements in head and trunk sway were greater in the segmental training group at primary endpoint but not at follow-up.

The role of the paravertebral muscles in adolescent idiopathic scoliosis evaluated by temporary paralysis.

BACKGROUND: Muscle imbalance has been suggested as implicated in the pathology of adolescent idiopathic scoliosis (AIS). The specific "pathomechanic" role of the paravertebral muscles as being scoliogenic (inducing scoliosis) or counteracting scoliosis in the initial development and maintenance of this spinal deformity has yet to be clarified in humans. In the present study, we investigated the radiographic changes of temporal paralysis using botulinum toxin A as localized injection therapy (ITB) in the psoas major muscle in AIS patients. METHODS: Nine patients with AIS were injected one time with ITB using ultrasonic and EMG guidance in the selected spine muscles. Radiographic and clinical examinations were performed before and 6 weeks after the injection. Primary outcome parameters of radiological changes were analyzed using Wilcoxon signed-rank test and binomial test, and secondary outcome parameters of short- and long-term clinical effects were obtained. RESULTS: Significant radiological corrective changes were seen in the frontal plane in the thoracic and lumbar spine as well as significant derotational corrective change in the lumbar spine according to Cobb's angle measurements and to Nash and Moe's classification, respectively. No serious adverse events were detected at follow-up. CONCLUSIONS: In conclusion, this study demonstrated that the psoas major muscle do play a role into the pathology in adolescent idiopathic scoliosis by maintaining the curvature of the lumbar spine and thoracic spine. TRIAL REGISTRATION: EudraCT number 2008-004584-19.

Stability and migration across femoral varus derotation osteotomies in children with neuromuscular disorders.

Background and purpose - Studies have indicated that one-third of children with cerebral palsy (CP) develop dislocation of the hip that needs surgical intervention. When hip dislocation occurs during childhood surgical treatment consists of tenotomies, femoral varus derotation osteotomy (VDRO), and acetabuloplasty. Relapse is observed in one-fifth of cases during adolescence. In this prospective cohort study, we performed a descriptive evaluation of translation and rotation across VDROs in children with neuromuscular disorders and syndromes by radiostereometric analysis (RSA). We assessed "RSA stability" and migration across the VDROs. Patients and methods - Children with a neuromuscular disorder were set up for skeletal corrective surgery of the hip. RSA follow-ups were performed postoperatively, at 5 weeks, and 3, 6, and 12 months after surgery. Results - 27 femoral VDROs were included; 2 patients were excluded during the study period. RSA data showed stability across the VDRO in the majority of cases within the first 5 weeks. At the 1-year follow-up, the mean translations (SD) of the femoral shaft distal to the VDRO were 0.51 (1.12) mm medial, 0.69 (1.61) mm superior, and 0.21 (1.28) mm posterior. The mean rotations were 0.39° (2.90) anterior tilt, 0.02° (3.07) internal rotation, and 2.17° (2.29) varus angulation. Interpretation - The migration stagnates within the first 5 weeks, indicating stability across the VDRO in most patients.

The Effect of Botulinum Toxin A Injections in the Spine Muscles for Cerebral Palsy Scoliosis, Examined in a Prospective, Randomized Triple-blinded Study.

STUDY DESIGN: A prospective, randomized triple-blinded cross-over design treating with either botulinum toxin A (BXT) or saline (NaCl). OBJECTIVE: To examine the efficacy of BTX treatment in cerebral palsy scoliosis (CPS). SUMMARY OF BACKGROUND DATA: Intramuscular injections with BTX have been used off label in treating CPS. 1 prospective study has been conducted, demonstrating in both radiological and clinical improvement, whereas showing no side effects or complications. METHODS: Subjects (brace-treated CPS between 2 and 18 yr) were injected using ultrasonic-guidance with either NaCl or BTX in selected spine muscles with 6 mo intervals (block randomization, sealed envelope). Radiographs of the spine and clinical follow-up were captured before and 6 weeks after each injection. Primary outcome parameter was radiological change in Cobb angle, where a 7° change was regarded as an effect (1 SD). Radiological parameters were measured before and 6 weeks after treatment by 3 experienced doctors separately. Moreover, clinical results were evaluated by the pediatric quality of life score and systematic open questioning of the parents about the child's wellbeing. Subjects, researchers, and monitors were blinded during the trial. Appropriate permissions (2008-004584-19) and no funding were obtained. RESULTS: 16 cerebral palsy patients (GFMCS III-V) with CPS were consecutively included, whereas 6 patients were excluded. There were no drop-outs to follow-up, but 1 possible serious adverse event of pneumonia resulting in death was recorded and the study was terminated. No significant radiological or clinical changes were detected when compared with NaCl injections using Wilcoxon matched pair signed-rank test. CONCLUSION: No positive radiological or clinical effects were demonstrated by this treatment, except for the parent's initial subjective but positive appraisal of the effect. However, the study was terminated due to 1 possible severe adverse event and scheduled numbers needed to treat (hence power) were not reached. LEVEL OF EVIDENCE: 1.

Measuring postural sway in sitting: a new segmental approach.

Global measures of trunk sway are traditionally used even though the trunk comprises a multiple number of segments. The authors' aim was to measure the seated sway of typically developing children using a multisegment approach. Twenty typically developing children divided into 2 groups, older and younger than 10 years old, participated in this study. The children sat unsupported for 30 s while their posture and sway were quantified using stereophotogrammetry. The tendency in both age groups was to sit with a backward tilted pelvis and a kyphotic trunk. The sitting position was most varied in the younger group. Marker sway amplitude and velocity in sitting were age dependent, with reduced sway amplitude and velocity with increased age for all segments. Anteroposterior intersegmental angular sway was not age dependent. The difference in marker sway in the anteroposterior direction for the younger group appeared to result from an equally stable trunk supported on a less stable pelvis. Mediolateral marker sway and intersegmental angular sway showed a clearer age dependency. Trunk postural control does not appear to differ between children older and younger than 10 years old, but sagittal plane pelvic stability can explain the increased sway reported in younger children.

Alternative outcome measures in young total hip arthroplasty patients: a prospective cohort study.

In this prospective multicentre cohort study we studied subjects younger than 60 years of age scheduled for primary total hip arthroplasty (THA). The study assessed patients' overall satisfaction, fulfillment of preoperative expectations, the effect on socioeconomic parameters, and quality of sex-life. Questionnaires including Oxford Hip Score (OHS) and SF-36 were evaluated preoperatively and 3, 6 and 12 months postoperatively. OHS and SF-36 showed significant improvements (p<0.028, Wilcoxon Signed Rank test). THA did not affect the patients' socioeconomic status. Increased frequency of intercourse or better abilities in intercourse positions were experienced by 18 of 39 females due to reduced pain and increased range of motion. Patients sexually active before THA surgery remained active. These findings constitute important new information to young patients and surgeons during the decision making process.

[Treatment of spasticity in children with cerebral palsy with botulinum toxin A]. / Behandling af spasticitet med botulinumtoksin hos børn med cerebral parese

Over the latest 30 years there has been an increasing use of botulinum toxin A injections in the lower limbs in children with cerebral palsy. However, the conclusions regarding effect of treatment in both randomized controlled and non-controlled trials have been inconclusive. One explanation may be that children with cerebral palsy do not always exhibit pure spasticity and/or dystonia of the affected muscles. Furthermore, the dose, injection volume and injection technique may vary from study to study. The evidence for the effect is so small that careful consideration on whether to continue this treatment regimen or not is needed.

The central role of trunk control in the gross motor function of children with cerebral palsy: a retrospective cross-sectional study.

AIM: Improvement of gross motor function and mobility are primary goals of physical therapy in children with cerebral palsy (CP). The purpose of this study was to investigate the relationship between segmental control of the trunk and the corresponding gross motor function in children with CP. METHOD: This retrospective cross-sectional study was based on 92 consecutive referrals of children with CP in Gross Motor Function Classification System (GMFCS) levels I to V, 39 females, 53 males (median age 4y [range 1-14y]), and 77, 12, and 3 with spastic, dyskinetic, and ataxic CP respectively. The participants were tested using the Gross Motor Function Measure (GMFM), the Pediatric Evaluation of Disability Inventory (PEDI), and the Segmental Assessment of Trunk Control (SATCo). RESULTS: Linear regression analysis showed a positive relationship between the segmental level of trunk control and age, with both gross motor function and mobility. Segmental trunk control measured using the SATCo could explain between 38% and 40% of variation in GMFM and between 32% and 37% of variation in PEDI. INTERPRETATION: This study suggests a strong association between segmental trunk postural control and gross motor function and mobility with significant clinical implications for the treatment of children with CP.

Multiple cartilaginous exostoses and development of chondrosarcomas--a systematic review.

INTRODUCTION: Hereditary multiple cartilaginous exostoses is a syndrome characterised by the development of multiple osteochondromas. The diagnosis is typically made around the age of 12 years, and the prevalence is estimated at 1:50,000. During skeletal growth, the osteochondromas are benign, but in adult life malignant transformation into chondrosarcomas can occur. METHODS: This study was a literature survey based on a systematic search of the PubMed database for articles with the term "hereditary multiple exostoses chondrosarcoma". The search returned 157 articles, of which 13 had a sufficient level of evidence. These publications were examined thoroughly, focusing on the development of sarcomas, symptoms and the risk of malignant degeneration. RESULTS: There is no consensus regarding the frequency of malignant transformation of multiple cartilaginous exostoses into sarcomas, which varies from less than 1% to 25%. The most reliable estimation seems to be 1-2%. The survey of the literature shows that no risk groups can be identified. However, exostoses in the axial skeleton are more prone to develop into chondrosarcomas than peripheral exostoses. CONCLUSION: It is indisputable that malignant transformation occurs, and we therefore propose that a follow-up programme be launched with clinical examination by magnetic resonance imaging or bone scintigraphy every second year. The purpose of such programme would be to discover the sarcomatous development as early as possible to improve the survival prognosis of the patients. This screening programme should be centralised at tumour departments.

Doctor's delay in diagnosis of slipped capital femoral epiphysis.

INTRODUCTION: Slipped capital femoral epiphysis (SCFE) is one of the most common hip disorders in the adolescent child. The primary treatment is acute epiphysiodesis. Diffuse symptomology seems to delay diagnosis and delayed treatment entails a risk of complications. Via the independent Danish Patient Insurance Association (DPIA), Danish patients have been able to file a claim when an unexpected side effect or injury has resulted from their medical treatment. The DPIA is based on a no-blame, no-fault case evaluation, which is free of charge and without any legal action. We wanted to examine the causes of complaints through closed claim analysis. MATERIAL AND METHODS: In the DPIA, all medical statements and internal DPIA notes are stored and available for detailed scrutiny. Cases from 1996 to 2011 were investigated for treatment failures. RESULTS: A total of 40 cases were included. The mean age of the children was 12.4 years. A doctor's delay (DD) of the diagnosis was found in 27 case files, with an average 181-day delay. The education and specialisation of the doctors responsible was diverse. Often orthopaedic surgeons would make the correct diagnosis. Complications to surgery were found in 16 cases. In all, 22 of the 40 cases were economially compensated, 16 cases were categorised as "severe disability" by the DPIA. CONCLUSION: This study used closed claim analysis to determine that DD might result in a deteriorated treatment result in children with SCFE. Hopefully, awareness of the disease may lead to an earlier correct diagnosis and hence improve the outcome for the child. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Tibial eminentia avulsion fracture in children - a systematic review of the current literature.

INTRODUCTION: Tibial eminentia avulsion fracture is the paediatric equivalent to a midsubstance anterior cruciate ligament injury. It is most common between the ages of 8 and 19 years of age. The incidence is three per 100,000 per year. We explored the clinical evaluation and classification of the fracture, indications for and methods of surgery and the possible sequelae. METHODS: We performed a systematic search in the PubMed database and retrieved 127 articles. A total of 16 articles met the defined inclusion criteria and were reviewed. Only studies on adolescents were included. RESULTS: No prospective studies were found. The Meyers & McKeever and Zaricznyj classifications were commonly used, also when evaluating fractures for surgery. X-ray in three views is often sufficient to establish a diagnosis, but computed topographies can be necessary to further evaluate the type of fracture. There is disagreement as to whether a type II-fracture needs surgery. The method of fixation varies greatly between different kinds of suture techniques and screw fixations, but arthroscopic surgery is preferred in the most recent literature. Whether to cross the physis when fixating the fracture is also a matter of dis-agreement, but there is a lack of literature on the subject. All authors describe low rates of subjective sequelae. CONCLUSION: Arthroscopic surgery is less invasive and allows for earlier mobilisation than other techniques. Pull-out suture seems to be a recommendable technique. There is a lack of literature on transphyseal fixation and a need for prospective studies evaluating the many different surgical techniques described and the indications for surgery.

Total knee arthroplasty in younger patients evaluated by alternative outcome measures.

In this prospective multicenter study we included subjects younger than 60 years of age and scheduled for primary total knee arthroplasty (TKA). The study assessed patients' overall satisfaction, fulfillment of preoperative expectations, the effect on socioeconomic parameters, and quality of sexual life. Questionnaires including Oxford Knee Score (OKS) and SF-36 were evaluated preoperatively and 3, 6, and 12 months postoperatively. OKS and SF-36 showed significant improvements. However, patient satisfaction and fulfillment of personal expectations did not reflect these scores. Overall, TKA did not affect the patients' socioeconomic status, and overall, patients did not experience impairment of sexual life, but decreased frequency and negative affection of sexual practice should be anticipated. Alternative outcome measurements of TKA surgery not focusing on implants and surgical techniques shed new light on important consequences of arthroplasty surgery.

Effects of training and weight support on muscle activation in Parkinson's disease.

The aim of this study was to investigate the effect of high-intensity locomotor training on knee extensor and flexor muscle activation and adaptability to increased body-weight (BW) support during walking in patients with Parkinson's disease (PD). Thirteen male patients with idiopathic PD and eight healthy participants were included. The PD patients completed an 8-week training program on a lower-body, positive-pressure treadmill. Knee extensor and flexor muscles activation during steady treadmill walking (3 km/h) were measured before, at the mid-point, and after training. Increasing BW support decreased knee extensor muscle activation (normalization) and increased knee flexor muscle activation (abnormal) in PD patients when compared to healthy participants. Training improved flexor peak muscle activation adaptability to increased (BW) support during walking in PD patients. During walking without BW support shorter knee extensor muscle off-activation time and increased relative peak muscle activation was observed in PD patients and did not improve with 8 weeks of training. In conclusion, patients with PD walked with excessive activation of the knee extensor and flexor muscles when compared to healthy participants. Specialized locomotor training may facilitate adaptive processes related to motor control of walking in PD patients.

The epidemiology of Schmorl's nodes and their correlation to radiographic degeneration in 4,151 subjects.

PURPOSE: Schmorl's nodes (SNs) are commonly seen in vertebral imaging of the normal adult population referred for different reasons and are duly noted by the radiologist. However, little is known about their etiology: either SNs are perceived as largely inert developmental or congenital herniations of disc tissue into weak areas of the vertebral end-plates, or they are perceived as a common pathological pathway of different adverse and general factors such as malignancy, trauma, infection, osteoporosis, Paget's disease and so forth. A commonly accepted morphological definition of what precisely constitute SNs does not exist, and consequently prevalences vary wildly in the literature. In the present study of 4,151 standardized lateral radiographs of the lumbar spine in an adult, Caucasian population between 22 and 93 years (median age 63 years, M 1,533, W 2,618). METHODS: We investigated prevalence, distribution and epidemiologic relationships of SNs. RESULTS: SNs occur primarily in the upper part of the lumbar spine, and usually there are multiple lesions in the same individual. We could not establish any significant correlation between SNs and gender, age, BMI, height, weight or occupational exposure for heavy lifting. The overall prevalence was 3.8%. We did not find any significant correlations between SNs and overall degeneration of the lumbar spine. CONCLUSION: We found a prevalence of SNs in the lower end of the spectrum than hitherto reported.

The alignment of the knee joint in relationship to age and osteoarthritis: the Copenhagen Osteoarthritis Study.

INTRODUCTION: The aim of the present study was to describe the changes in the axis of the knee joint in both radiologically osteoarthritic and non-osteoarthritic knees, on the basis of angles measurable in standardized clinical short knee radiographs, in a cross sectional study of an epidemiological cohort. DESIGN: From the third inclusion of the Copenhagen City Heart Study, 4,151 subjects were selected for standardized radiography of the knees. After censuring the inclusion, the resulting cohort was comprised of 3,488 individuals. Images were analyzed for radiological knee joint osteoarthritis (OA) and the anatomical femorotibial axis of the knee joint was measured. RESULTS: The prevalence of knee joint OA in males was 27.9% and 27.5%, for the left and right knees respectively. In females this was 32.8% and 36.4%. The mean knee joint angles were 4.11° in males; and 5.45° in females. A difference of 1.3° was found between the genders. In non-osteoarthritic knees the increase in valgus orientation in relationship to increasing age was found to be 0.03° and 0.04° per year, respectively, for males and females. Likewise, Kellgren and Lawrence found that OA was seen to influence a shift towards varus of 0.55°-0.76° per level of OA. CONCLUSION: Stratification in accordance with morphological severity of OA documented a clear tendency for the axis of the diseased knees to depart from the mean, primarily in the direction of varus. In knees exhibiting no signs of radiographic osteoarthritis we found a significant relationship between increasing age and a shift in the anatomical axis in the direction of valgus.

Tremor irregularity, torque steadiness and rate of force development in Parkinson's disease.

We investigated lower-extremity isometric tremor Approximate Entropy (irregularity), torque steadiness and rate of force development (RFD) and their associations to muscle activation strategy during isometric knee extensions in patients with Parkinson's disease (PD). Thirteen male patients with idiopathic PD and 15 neurologically healthy matched controls performed isometric maximal contractions (extension/flexion) as well as steady submaximal and powerful isometric knee extensions. The patients with PD showed decreased isometric tremor irregularity. Torque steadiness was reduced in PD and the patients had increased muscle coactivation. A markedly lower RFD was found in PD and the decreased RFD correlated with reduced agonist muscle activation. Furthermore, patient RFD correlated with the Movement-Disorder-Society-Unified-Parkinson's-Disease-Rating-Scale 3 (motor part) scores. We concluded that both knee isometric tremor Approximate Entropy and torque steadiness clearly differentiate between patients with PD and healthy controls. Furthermore, severely compromised RFD was found in patients with PD and was associated with decreased agonist muscle activation.

Improved clinical status, quality of life, and walking capacity in Parkinson's disease after body weight-supported high-intensity locomotor training.

OBJECTIVE: To evaluate the effect of body weight-supported progressive high-intensity locomotor training in Parkinson's disease (PD) on (1) clinical status; (2) quality of life; and (3) gait capacity. DESIGN: Open-label, fixed sequence crossover study. SETTING: University motor control laboratory. PARTICIPANTS: Patients (N=13) with idiopathic PD (Hoehn and Yahr stage 2 or 3) and stable medication use. INTERVENTIONS: Patients completed an 8-week (3 × 1h/wk) training program on a lower-body positive-pressure treadmill. Body weight support was used to facilitate increased intensity and motor challenges during treadmill training. The training program contained combinations of (1) running and walking intervals, (2) the use of sudden changes (eg, in body weight support and speed), (3) different types of locomotion (eg, chassé, skipping, and jumps), and (4) sprints at 50 percent body weight. MAIN OUTCOME MEASURES: The Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Parkinson's Disease Questionnaire-39 items (PDQ-39), and the six-minute walk test were conducted 8 weeks before and pre- and posttraining. RESULTS: At the end of training, statistically significant improvements were found in all outcome measures compared with the control period. Total MDS-UPDRS score changed from (mean ± 1SD) 58±18 to 47±18, MDS-UPDRS motor part score changed from 35±10 to 29±12, PDQ-39 summary index score changed from 22±13 to 13±12, and the six-minute walking distance changed from 576±93 to 637±90m. CONCLUSIONS: Body weight-supported progressive high-intensity locomotor training is feasible and well tolerated by patients with PD. The training improved clinical status, quality of life, and gait capacity significantly.

Neurorehabilitation with versus without resistance training after botulinum toxin treatment in children with cerebral palsy: a randomized pilot study.

OBJECTIVE: To compare the effects of physical rehabilitation with (PRT) and without (CON) progressive resistance training following treatment of spastic plantarflexors with botulinum toxin type A (BoNT) in children with cerebral palsy (CP). METHODS: Fourteen children with CP performed supervised PRT (n=7) or CON (n=7) two times per week for 12 weeks, following the BoNT-treatment. Outcome measurements were performed at baseline (pre BoNT), and 4 and 12 weeks post BoNT. They consisted of: ankle muscle function (maximal torque and submaximal torque steadiness of isometric ankle dorsi- and plantarflexion and associated ankle muscle [EMG] activity), gait function (3-dimensional gait analysis), balance function (sway analysis), gross motor function (GMFM-66), and spasticity (modified Ashworth). RESULTS: Submaximal torque control (torque steadiness) of isometric dorsiflexion improved similarly in the two groups, and the improvement was related to the reduction in antagonist (soleus) co-activity (P< 0.05). Maximal plantarflexion torque increased after PRT, whereas a reduction was seen after CON (P< 0.05). No changes in function were observed. CONCLUSIONS: Both types of physical rehabilitation in combination with BoNT-treatment improved antagonist (ankle dorsiflexion) torque-control to the same extent - which was related to the reduction in antagonist co-activity - but only rehabilitation with PRT increased maximal plantarflexion torque.

Measuring medial longitudinal arch deformation during gait. A reliability study.

Clinical evaluation of medial longitudinal arch deformation (MLAD) during walking gait is often estimated from static measures of e.g. navicular drop (ND) measured during quiet standing. The aim of the present study was to test the reliability of a new three-dimensional method of measuring the MLAD during gait and to compare this method with a static measure and a 2D dynamic method. Fifty-two feet (26 healthy male participants) were tested twice 4-9 days apart in a biomechanical gait analysis laboratory using a 3D three-marker foot model, a 2D video-based model for the measurement of MLAD during gait, and ND for measurements of MLAD during quiet standing. The 3D method showed the highest test-retest reliability among the measurements of MLAD. Furthermore, the ND showed only moderate correlation with both measurements of MLAD during gait. The new 3D method was found to be highly reliable and showed that ND obtained during quiet standing could not predict the MLAD during gait. The 3D method, or alternatively the 2D method, may be used in clinical settings as reliable methods for easy estimation of the foot longitudinal stability.