Self-reported Health-related Quality of Life in Adolescents With Cerebral Palsy.

BACKGROUND: Happiness, comfort, and motor function contribute to satisfaction with life for individuals with cerebral palsy (CP). Evidence-based medical care can improve motor function and physical health of youth with CP. Less is known about medical care and its relationship to health-related quality of life (HRQOL) in adolescents and young adults with CP. This study aimed to describe HRQOL among adolescents with CP to examine differences between adolescent (self) and parent (proxy) reports of HRQOL and to explore associations of pain, age, and gross motor function with HRQOL. METHODS: This is a retrospective study including adolescents with CP classified as Gross Motor Function Classification System levels I to V, ages 11 to 20 years, reading ≥ a fourth-grade level, and who completed the self-reported Pediatric Outcomes Data Collection Instrument (PODCI). Parents completed the PODCI concurrently or within 12 months and scores were compared. In addition, self-reported scores were compared between age bands, across Gross Motor Function Classification System levels, with typically developing youth (TDY), and between youth with/without pain. RESULTS: PODCI scores from 102 adolescents [59 males; 15.0 (SD: 2.6) years old] were examined. Scores from 50 adolescents and parents were matched. Mean self-reported scores were significantly higher than mean parent-reported scores in 4 domains: upper extremity and physical function ( P =0.018), sports and physical function ( P =0.005), happiness ( P =0.023), and global functioning ( P =0.018). All domains, except Happiness, were significantly < TDY ( P <0.01). The presence of pain was associated with lower scores in all domains ( P <0.05). CONCLUSION: Examining HRQOL with the PODCI revealed significant limitations in physical function and higher pain in adolescents with CP compared with TDY. Self- and parent-reported PODCI results should be considered separately. Adolescents report higher HRQOL compared with parent proxy. Recognizing and validating the perspectives of youth and their parents presents an opportunity for providers to discuss different points of view with families. Such engagement can help promote self-efficacy in youth with CP as they transition to the responsibility of guiding their own care in adulthood. LEVEL OF EVIDENCE: III, Retrospective comparative study.

Association of herd hyperketolactia prevalence with transition management practices and herd productivity on Canadian dairy farms-A retrospective cross-sectional study.

The objective of this observational study was to assess the relationship between herd-level prevalence of hyperketolactia (HPH) with management practices of the transition period and herd milk production. Dairy herds (n = 71) were selected based on their inclusion in a herd management risk assessment study (August 2014-March 2018) using a Vital 90 (Elanco) Risk Assessment tool (one assessment per farm). Data from multiple milk recording test-days (Dairy Herd Improvement, DHI; Lactanet) were included in the analysis. Tests performed within ±6 mo relative to each farm's risk assessment date were included (10 ± 2 SD tests per farm). The majority of the farms were located in Ontario (83%). For each farm DHI test, the data set included herd average milk yield (kg/cow per day), average milk fat and protein (%), average somatic cell count (cells/mL), average days in milk (DIM), number of cows tested for ketosis, number of ketosis-positive tests (milk ß-hydroxybutyrate ≥0.15 mmol/L), and proportion of cows by parity groups. Overall HPH (5-21 DIM) was calculated based on data available per farm (sum of all positive tests within 5-21 DIM/sum of all cows tested within 5-21 DIM). Each farm average was obtained by considering all test-days. A logit-transformation was applied to hyperketolactia prevalence. Linear regression models (PROC GLM and MIXED of SAS, Version 9.4) were used to predict herd HPH (milk ß-hydroxybutyrate ≥0.15 mmol/L within 5 to 21 DIM; the outcome of interest). Four initial models (far-off, close-up, and fresh periods, and DHI) were separately built to assess associations between their variables and HPH; a final model considered variables selected in the initial models. Univariable (liberal P < 0.25) followed by multivariable models were used to build specific models for each period of the risk assessment. Herd prevalence of hyperketolactia was 27 ± 14%, with an average herd size of 141 ± 110 cows. The final HPH model (R2 = 24.8%) included weighted milk yield, the proportion of primiparous cows, water access in the close-up period, and access to rest areas or stall access in the fresh period. Herd prevalence of hyperketolactia was negatively associated with milk yield [odds ratio, OR = 0.96 (95% confidence interval 0.92-0.99)] and proportion of primiparous cows [OR = 0.98 (0.96-0.99)]. The odds of hyperketolactia were greater with poor water access and quality (<5 cm of linear access per cow; dirty water; only 1 water location in pen) than with ≥10.2 cm of linear access per cow; clean water; >2 water locations in pen [1.23 (1.11-2.39)] in the close-up period. The odds of hyperketolactia were greater in farms providing limited access to rest areas in the fresh period than in farms providing constant access to rest areas, without dead-ends [1.64 (1.03-2.80)]. In Canadian dairy herds, HPH in early lactation was associated with certain transition-period management practices and was negatively associated with herd productivity.

The Effectiveness of Serial Casting in the Treatment of Recurrent Equinovarus in Children With Arthrogryposis.

BACKGROUND: Arthrogryposis multiplex congenita (AMC) is characterized by joint contractures in 2 or more body areas, often resulting in clubfoot deformities that are typically stiffer than those seen in idiopathic clubfoot deformities. While surgery is routinely used to treat clubfoot in AMC, it has a high rate of recurrence and complications. Current literature suggests serial casting (SC) could be useful in treating clubfoot in AMC, though evidence of its effectiveness is limited. METHODS: Passive range of motion (PROM), dynamic foot pressure, parent-reported Pediatric Outcomes Data Collection Instrument, brace tolerance, and the need for post-casting surgery were evaluated retrospectively in children with AMC treated with SC to address clubfoot deformities. Analysis of variance or paired t tests were used as appropriate on pre-casting, short-term (within 6 mo after SC) and/or longer-term (6 to 18 mo after SC) parameters to determine the effectiveness of SC. Brace tolerance before and after SC was analyzed using the Global Test for Symmetry, and medical records were reviewed to determine the need for surgery post-SC. RESULTS: Forty-six children (6.1±3.1 y old) were cast an average of 2.5±1.9 times, resulting in 206 SC episodes. PROM showed improvement in ankle dorsiflexion and forefoot abduction in the short term (P<0.05), returning to baseline measurements in the long term (P=0.09). Brace tolerance improved after casting (P<0.05). Only 15% of feet required surgery at follow-up at 10.3±5.5 years. There were no significant changes in dynamic foot pressure or Pediatric Outcomes Data Collection Instrument results after SC, except for an increase in the pain subtest (P<0.05). CONCLUSIONS: Serial casting in children with AMC can be effective in temporarily improving PROM and improving brace tolerance, but it does not impact dynamic barefoot position. Positive impact of conservative management in children with AMC can potentially delay or reduce the need for invasive surgical intervention by improving PROM and brace tolerance. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Is Standing Function Improved After Orthopaedic Surgery in Children With Cerebral Palsy at GMFCS Levels III/IV?

BACKGROUND: Children with cerebral palsy (CP) at Gross Motor Function Classification System (GMFCS) levels III/IV are at risk for losses in standing function during adolescence and transition to adulthood. Multilevel surgery (MLS) is an effective treatment to improve gait, but its effects on standing function are not well documented. The objectives of our study were to describe standing function in children with CP classified as GMFCS levels III/IV and evaluate change after MLS. METHODS: This retrospective study included children with CP (GMFCS III/IV) ages 6 to 20 years who underwent instrumented gait analysis. A subset who underwent MLS were evaluated for change. Primary outcome measures were Gross Motor Function Measure dimension D, gait velocity, functional mobility scale, and the Pediatric Outcomes Data Collection Instrument (PODCI). Additional impairment level measures included foot pressure, knee extension during stance phase of gait, and knee extension passive range of motion. RESULTS: Four hundred thirty-seven instrumented gait analysis sessions from 321 children with CP (ages 13.7±4.8 y; GMFCS III-81%/IV-19%) were included. The GMFCS III group had higher Gross Motor Function Measure dimension D, gait velocity, PODCI scores, and better knee extension compared with the GMFCS IV group ( P <0.05); 94 MLS were evaluated for postoperative change 15.3±4.2 months after MLS. Children at GMFCS level III had improved PODCI scores ( P <0.05), better knee extension passive range of motion ( P <0.01), and improved coronal plane foot pressure ( P <0.05) post MLS. Maximum knee extension during stance and heel impulse improved significantly in both groups ( P <0.01). CONCLUSIONS: Standing function of children with CP at GMFCS IV was significantly more limited than at GMFCS III. After MLS, both groups (III/IV) showed improvement in impairment level outcomes (knee extension and foot position), whereas only those functioning at GMFCS III had improvement in activity/participation outcomes according to the PODCI. For children with CP at GMFCS levels IV, MLS may improve standing function, but appropriate goals related to assisted standing and measurement protocols sensitive to limited functional mobility should be adopted. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Can the Shriners Hospital Upper Extremity Evaluation (SHUEE) Detect Change in Dynamic Position and Spontaneous Function of the Upper Limb in People With Hemiplegic Cerebral Palsy?

BACKGROUND: The Shriners Hospital Upper Extremity Evaluation (SHUEE) is a video-based measure designed to assess upper extremity function in people with cerebral palsy (CP). The SHUEE completes both dynamic positional analysis (DPA; position during functional activities) and spontaneous functional analysis (spontaneous use of the involved limb). Although the SHUEE has been suggested as a measure for planning upper limb interventions and evaluating outcomes, limited evidence of its ability to detect change exists. Thus, this study aimed to describe responsiveness of the SHUEE to detect change after orthopaedic surgery. METHODS: In this Institutional Review Board-approved retrospective cohort study, we identified children with CP who were administered SHUEE on≥2 encounters. We formed pairs of initial and follow-up visits between temporally adjacent visits. Pairs were assigned to a surgery or non-surgery group based on intervening upper limb orthopaedic surgery. We compared differences in baseline SHUEE scores between groups and differences in temporally adjacent SHUEE scores within groups using Welch unequal variances t tests and paired t tests, respectively. RESULTS: Nineteen people (7 female) with hemiplegic CP had≥2 SHUEE assessments; Manual Ability Classification System levels I (3), II (8), III (7), IV (1); Gross Motor Function Classification System levels I (10), II (7), IV (2); mean age at baseline 11.9 (5.1 to 19.1) years; and follow-up at 13.4 (5.5 to 19.7) years. Six people had≥2 visits leading to 14 surgical pairs and 10 non-surgical pairs. At baseline, DPA of the wrist and forearm were significantly lower in the surgical group ( P <0.05). At follow-up, no significant difference between the groups existed in DPA measures ( P >0.05). After surgical intervention, there was a significant change in overall and wrist DPA ( P <0.05). CONCLUSIONS: The DPA measures demonstrated responsiveness to expected positional changes in the arm after orthopaedic surgery in people with CP. The SHUEE was useful in identifying abnormal segmental alignment pre-surgically and documenting changes in alignment postoperatively. As orthopaedic surgery does not address limb neglect or bimanual ability, spontaneous functional analysis scores were as expected-unchanged. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Walking activity after multilevel orthopedic surgery in children with cerebral palsy.

AIM: To determine how surgical burden and preoperative factors affect the recovery of walking activity after multilevel orthopedic surgery (MLS). METHOD: In this retrospective study, inclusion criteria were a diagnosis of cerebral palsy, MLS, and walking activity monitoring using a StepWatch device within 12 months pre-MLS and 24 months post-MLS. The outcome measure was total mean strides per day normalized to age and Gross Motor Function Classification System level. Pre- and postoperative walking activity were compared using unpaired t-tests; the effects of preoperative predictors and surgical burden on the recovery of walking activity were evaluated using regression analysis. RESULTS: Participants included 178 children (mean age 12 years 10 months [SD 8 years 7 months; range 4-20 years]; 91 males, 87 females). On average, children returned to baseline walking activity 3 months after low-burden surgery and 1 year 2 months after high-burden surgery. Postoperative walking activity was higher for children who had surgery at a younger age and those with a higher preoperative mobility function. INTERPRETATION: The burden of MLS was found to be inversely related to the time to recovery of postoperative walking activity. These findings provide evidence to help clinicians set expectations for return to function post-MLS. Further study is necessary to investigate the impact of postoperative factors on walking activity recovery. WHAT THIS PAPER ADDS: High-burden surgeries lead to longer recovery than low-burden surgeries. Younger children recover walking activity faster after multilevel orthopedic surgery. Children with high preoperative mobility function recover walking activity faster after surgery.

OBJETIVO: Determinar como a carga cirúrgica e os fatores pré-operatórios afetam a recuperação da atividade de caminhada após cirurgia ortopédica multinível (MLS). MÉTODOS: Neste estudo retrospectivo, os critérios de inclusão foram um diagnóstico de paralisia cerebral, MLS e monitoramento da atividade de caminhada usando um dispositivo Step Watch dentro de 12 meses pré-MLS e 24 meses pós-MLS. A medida de resultado foi o total de passos médios por dia normalizados para idade e nível do Sistema de Classificação da Função Motora Grossa. A atividade de caminhada pré e pós-operatória foi comparada usando testes t não pareados; os efeitos dos preditores pré-operatórios e da carga cirúrgica na recuperação da atividade de caminhada foram avaliados por meio de análise de regressão. RESULTADOS: Os participantes incluíram 178 crianças (idade média de 12 anos e 10 meses [DP 8 anos e 7 meses; intervalo de 4 a 20 anos]; 91 meninos, 87 meninas). Em média, as crianças retornaram à atividade de caminhada inicial 3 meses após a cirurgia de baixa carga e 1 ano e 2 meses após a cirurgia de alta carga. A atividade de caminhada pós-operatória foi maior para crianças que foram operadas em idade mais jovem e aquelas com maior função de mobilidade pré-operatória. INTERPRETAÇÃO: A carga de MLS foi inversamente relacionada ao tempo de recuperação da atividade de caminhada pós-operatória. Esses achados fornecem evidências objetivas para ajudar os médicos a definir as expectativas de retorno à função pós-MLS. Mais estudos são necessários para investigar o impacto dos fatores pós-operatórios na recuperação da atividade de caminhada.

Residual Deformity and Outcome of Ambulatory Adults With Cerebral Palsy: A Long-term Longitudinal Assessment.

BACKGROUND: Advances in pediatric orthopaedic care have improved mobility and function for children with cerebral palsy (CP) as mobility declines from adolescence into adulthood. The long-term effectiveness of modern orthopaedic care is not widely reported. This study aimed to report the pediatric orthopaedic surgical burden, residual deformities, and outcomes using objective evidence of mobility in ambulatory adults with CP. METHODS: An institutional review board-approved prospective cohort study was performed in ambulatory adults with CP between 25 and 45 years, who had an adolescent gait analysis. Orthopaedic interventions were reviewed, and adolescent and adult gait analyses were compared using paired 2-tailed t tests. Adults were categorized by the presence of no, mild, or severe residual deformities in rotation, crouch, stiff knee, equinus, and foot deformity. RESULTS: Of 106 adults with CP, Gross Motor Function Classification System (GMFCS) distribution was grade I (22%), II (50%), III (23%), and IV (5%). Sixty-one males and 45 females were tested. The average age was 30±4 years with follow-up of 13±4 years since previous analysis; 279 surgical events (1165 procedures) were performed with a mean per patient of 2.6 events and 11 procedures. Comm on procedures were gastrocsoleus complex (88%) and hamstring lengthening (79%). The mean gait deviation index at adolescent and adult visit were 72.7±13 and 72.3±13 (P=0.78). Mean gait velocity at the adolescent visit was 85±27 and 79±31 cm/s at adult visit (P=0.02). Both gait deviation index and gait velocity change were clinically insignificant. Fifty-seven adults (81 limbs, 54%) had mild residual deformities. Residual hip internal rotation, pes planovalgus, and crouch gait were common. Severe deformities impacting function or causing pain were present in 11 participants (14 limbs, 10%). Seven of the 11 adults with severe deformities were worse compared with their adolescent evaluation; 4 were unchanged. CONCLUSIONS: Correcting deformities before adulthood has lasting stability with little functional loss in most ambulatory young adults with CP. Increasing deformity after adolescence can occur in young adults but is uncommon. LEVEL OF EVIDENCE: Level III.

Comparison of Surgical Outcomes for Distal Rectus Femoris Transfer and Resection Surgeries in Children With Cerebral Palsy With Stiff Knee Gait.

BACKGROUND: Children with cerebral palsy (CP) often present with a stiff knee gait pattern because of rectus femoris (RF) spasticity and/or contracture. Rectus femoris transfers (RFTs) and resections are surgical procedures aimed at reducing muscle stiffness, thereby improving knee flexion during the swing phase of gait. Previous research has consistently demonstrated objective benefits of rectus transfer using instrumented gait analysis (IGA). Rectus femoris resection (RFR), a relatively simpler procedure, shows similar improvement in knee range of motion during gait. The objective of this study was to compare surgical outcomes between rectus transfers and resections using 3-dimensional IGA. METHODS: Children with spastic CP who had RFTs or resections were retrospectively matched by walking speed and preoperative knee kinematics from 3-dimensional IGA (peak and timing of peak knee flexion in swing). Secondary outcomes included knee range of motion and maximum knee extension during gait. RESULTS: Twenty-eight children were included in both the transfer group [age 9.4±2 y; Gross Motor Function Classification System (GMFCS) I (3 children), II (15 children), III (8 children), and IV (2 children)] and the resection group [age 10.6±2.5 y; GMFCS I (1 child), II (14 children), and III (13 children)]. Both surgical groups showed statistically significant short-term postsurgical improvements in peak knee flexion during swing (P<0.001 for the transfer group and P=0.003 for the resection group) and Duncan-Ely test (P=0.004 for the transfer group and P<0.001 for the resection group). Further analysis by GMFCS level showed children at GMFCS levels III/IV had a greater tendency to crouch after RFT when compared with children at GMFCS levels I/II. This tendency was not observed in the RFR group. CONCLUSIONS: Both transfer and resection surgeries significantly improved gait kinematics short-term outcomes in children with spastic CP who present with stiff knee gait pattern. Further studies are required to compare long-term outcomes of both surgeries. LEVEL OF EVIDENCE: Level III-retrospective matched-cohort study.

The 5-Year Outcome of the Ponseti Method in Children With Idiopathic Clubfoot and Arthrogryposis.

BACKGROUND: The Ponseti method effectively treats idiopathic clubfoot, but its effectiveness in treating the stiffer clubfoot associated with arthrogryposis is less clear. The purpose of this study was to assess the comparative effectiveness of the Ponseti method in 5-year-old children with either idiopathic clubfoot or clubfoot due to arthrogryposis. METHODS: The outcomes of the Ponseti method were retrospectively evaluated in children with idiopathic clubfoot and clubfoot associated with arthrogryposis. The children with clubfoot were seen at our hospital between 2012 and 2019 and were 4.0 to 6.9 years old at the time of their evaluation. Outcomes of the 2 groups of children with clubfoot were assessed using passive range of motion, foot pressure analysis, the Gross Motor Function Measure Dimension-D, and parent report using the Pediatric Outcomes Data Collection Instrument. These results were also compared with the same measures from a group of typically developing children. Surgical and bracing history was also recorded. RESULTS: A total of 117 children were included (89 idiopathic clubfoot and 28 associated with arthrogryposis) with an average age of 4.8±0.8 years. The historical gait analyses of 72 typically developing children were used as a control, with an average age of 5.2±0.8 years. Significant residual equinovarus was seen in both children with idiopathic clubfoot and associated with arthrogryposis according to passive range of motion and foot pressure analysis when compared with normative data. Children with arthrogryposis demonstrated limited transfer and basic mobility, sports functioning, and global functioning while children with idiopathic clubfoot were significantly different from their typically developing peers in only transfer and basic mobility. CONCLUSIONS: Although children with idiopathic clubfoot continue with some level of residual deformity, the Ponseti method is effective in creating a pain-free, highly functional foot. In children with clubfoot associated with arthrogryposis, the Ponseti method is successful in creating a braceable foot that can delay the need for invasive surgical intervention. LEVEL OF EVIDENCE: Level III, Therapeutic Studies-Investigating the Results of Treatment.

Gait Analysis Parameters and Walking Activity Pre- and Postoperatively in Children With Cerebral Palsy.

PURPOSE: This study examined the relationship between the Gait Deviation Index (GDI) and walking activity preoperatively and postoperatively. METHODS: The GDI and walking activity from 74 youth with cerebral palsy (CP) were included in the analysis. The preoperative GDI was calculated using gait parameters collected during a clinical gait analysis 1 to 16 months prior to surgery. The postoperative GDI was calculated using gait parameters collected during a clinical gait analysis 10 to 26 months following surgery. RESULTS: A weak correlation was present between the change in the average GDI and the change in strides. A moderate correlation was found between the change in the Surgery GDI and the change in strides. CONCLUSION: Single-event multilevel surgery improves gait deviations in children with CP. However, the improvement in gait pattern has limited correlation with postoperative change in walking activity. Our results demonstrate a need to pair surgical with additional intervention to affect long-term improvements in walking activity.

Long-term Outcome of Internal Tibial Derotation Osteotomies in Children With Cerebral Palsy.

BACKGROUND: External tibial torsion (ETT) is a common bony deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome following TDO to correct ETT in ambulatory children with CP. METHODS: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ETT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, E0 MTR, E0 gait velocity, gross motor function classification system (GMFCS) score, and foot deformity were evaluated to determine their influence on long-term results. RESULTS: The study sample consisted of 43 legs (with E0 and E2) and 22 legs (with E0, E1, and E2). The mean age at surgery was 10.3±3.4 years (range, 6 to 19.2 y). In the group MTR trended toward improvement moving from -26±17 degrees (E0, external negative) to -16±16 degrees (E1) and relapsed to -23±17 degrees at the long term (P=0.071, E0/E1; P=0.589, E0/E2). Improvement was also seen in the transmalleolar axis (P=0.074), mean ankle rotation, and mean foot orientation (P<0.05, E0/E2). At the long-term evaluation, 16 legs (37%) were found to be in the kinematic corrected group, 25 legs (58%) in the kinematic undercorrected group, and 2 legs (5%) in the kinematic overcorrected group. There were no significant differences between the corrected and undercorrected groups of children with respect to age at surgery, GMFCS, E0 MTR, gait velocity, or foot deformity. CONCLUSIONS: Although internal TDO improves ETT in the short term, recurrence is frequent with an apparent developmental trend toward external rotation of the tibia. LEVELS OF EVIDENCE: Level IV-therapeutic study.

Long-term Outcome of External Tibial Derotation Osteotomies in Children With Cerebral Palsy.

BACKGROUND: Internal tibial torsion (ITT) is a common boney deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome after external TDO performed to correct ITT in ambulatory children with CP. METHODS: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ITT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing the subjects mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, preop MTR (at E0), preop gait velocity (at E0), gross motor function classification system score, and foot deformity were evaluated to determine their influence on long-term results. RESULTS: The study sample consisted of 36 legs (with E0 and E2) and 17 legs (with E0, E1, and E2). The mean age at surgery was 7.4±2.8 (range, 4 to 16.6) years. Comparing the changes over time, kinematic MTR improved from 17±11 degrees initially (E0) to -10±14 degrees short term (E1) and progressed to -23±13 degrees long term (E2) (P<0.05 E0/E1/E2; internal rotation is positive). At E2, 16 legs (44%) were found to be in the kinematic corrected group and 20 legs (56%) in the kinematic overcorrected group. There were no significant differences between the corrected and overcorrected groups of children in respect to age of surgery, gross motor function classification system, E0 MTR, gait velocity, or foot deformity. CONCLUSIONS: Although external TDO is an accepted form of treatment in children with CP, in the long term a tendency to move into external tibial torsion is common. Therefore, caution is warranted with children who initially present with ITT to avoid overcorrection. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Persistence and Recurrence Following Femoral Derotational Osteotomy in Ambulatory Children With Cerebral Palsy.

BACKGROUND: Excessive hip internal rotation is frequently seen in children with cerebral palsy (CP). Femoral derotational osteotomy (FDO) is effective in the short term, but factors associated with long-term correction remain unclear. The purposes of this study were to define the incidence of persistence and recurrence of hip internal rotation following FDO in ambulatory children with CP and to evaluate factors that influence outcome. METHODS: Following IRB approval, kinematic and passive range of motion (PROM) variables were retrospectively evaluated in children with spastic CP who had FDO to correct hip internal rotation as part of clinical care at a children's specialty hospital. Children included had a preoperative evaluation (Vpre), a short-term postoperative evaluation (Vshort, 1 to 3 y post), and, in some cases, a long-term postoperative evaluation (Vlong, ≥5 y post). Age at surgery, physical exam measures, and kinematics variables were evaluated as predictors for dynamic and static recurrence. RESULTS: Kinematic hip rotation improved from 14±12 degrees (Vpre; internal positive) to 4±13 degrees (Vshort) and relapsed to 9±15 degrees long term (P<0.05 Vpre/Vshort/Vlong; 99 limbs). Hip PROM midpoint improved from 23±9 degrees (Vpre) to 8±11 degrees (Vshort) and relapsed to 14±13 degrees (P<0.01 Vpre/Vshort/Vlong). Persistent hip internal rotation was noted in 41% (kinematics) and 18% (PROM) of limbs at Vshort (105 children, 178 limbs). Of limbs that showed initial improvement at Vshort (62 children, 95 limbs), recurrence was seen in 40% (kinematic hip rotation) and 39% (hip midpoint) at Vlong. Comparing children who had recurrent hip internal rotation and those who maintained long-term correction, we saw higher levels of spasticity and lower gait velocity in the recurrent group (P<0.05). CONCLUSIONS: Although FDO is an accepted treatment in children with CP, persistence and recurrence of hip internal rotation can occur. Recurrence is associated with spasticity and slower gait velocity. Predictor variables may be useful for surgeons during preoperative discussions of expected outcome with families of FDO candidates. LEVEL OF EVIDENCE: Level III.

Single-Leg Squat Performance in Active Adolescents Aged 8-17 Years.

Agresta, CE, Church, C, Henley, J, Duer, T, and O'Brien, K. Single-leg squat performance in active adolescents aged 8-17 years. J Strength Cond Res 31(5): 1187-1191, 2017-More than 30 million U.S. adolescents participate in sport and exercise. Lower extremity injury from sport participation accounts for up to 89% of injuries each year. The single-leg squat (SLS) is a simple clinical tool that assesses lower extremity mechanics often associated with injury risk. To date, there is limited information regarding SLS performance in healthy children. Such information could be useful when assessing youth athletes to determine if mechanics demonstrated are different than is to be expected and puts them at the risk for injury. Furthermore, maturity status is thought to influence motor performance. Currently, there is no information regarding the influence of maturity status on SLS performance in adolescents. The purpose of our study was to determine SLS performance in relation to age and maturity level in adolescents. Forty-five children aged 8-17 years were videotaped performing a series of 10 squats using a standardized protocol. Standing height, seated height, and leg length measures were collected. Investigators scored the SLS test using specific scoring criteria. Adolescents were categorized into 3 maturity levels using a peak height velocity calculation. Multiple linear regression analyses and analysis of variance were used to analyze the data. Chronological age was a significant predictor of SLS performance with younger children having poorer SLS scores. Coaches and trainers should consider the chronological age of the youth athlete when assessing SLS performance. Furthermore, tailored training programs by age may help to address faulty areas, like single-leg stability, and improve overall functional performance.

Developing a Clinical Protocol for Habitual Physical Activity Monitoring in Youth With Cerebral Palsy.

PURPOSE: The StepWatch (SW) has been used to monitor physical activity (PA) in youth with cerebral palsy; however, there is no standard collection protocol. The goal was to develop such a protocol. METHODS: Data were examined from patients who wore the SW for 8 to 14 days. The Spearman-Brown prediction formula determined the minimum number of days for reliable PA. Weekdays were compared to weekends and 10- and 60-second collection intervals were examined. RESULTS: The PA data were collected from 98 youth with cerebral palsy. Results showed 3 days would provide reliable representation of PA, participants took significantly more steps during school days compared with weekends, and there were no differences between collection intervals. CONCLUSIONS: We recommend setting the SW for 7 days at 10-second collection rate. Data should be analyzed if at least 3 days of data are present. Weekdays and weekend days should be noted, and both included when possible.

Role for the obesity-related FTO gene in the cellular sensing of amino acids.

SNPs in the first intron of FTO (fat mass and obesity associated) are strongly associated with human obesity. While it is not yet formally established that this effect is mediated through the actions of the FTO protein itself, loss of function mutations in FTO or its murine homologue Fto result in severe growth retardation, and mice globally overexpressing FTO are obese. The mechanisms through which FTO influences growth and body composition are unknown. We describe a role for FTO in the coupling of amino acid levels to mammalian target of rapamycin complex 1 signaling. These findings suggest that FTO may influence body composition through playing a role in cellular nutrient sensing.

Adult onset global loss of the fto gene alters body composition and metabolism in the mouse.

The strongest BMI-associated GWAS locus in humans is the FTO gene. Rodent studies demonstrate a role for FTO in energy homeostasis and body composition. The phenotypes observed in loss of expression studies are complex with perinatal lethality, stunted growth from weaning, and significant alterations in body composition. Thus understanding how and where Fto regulates food intake, energy expenditure, and body composition is a challenge. To address this we generated a series of mice with distinct temporal and spatial loss of Fto expression. Global germline loss of Fto resulted in high perinatal lethality and a reduction in body length, fat mass, and lean mass. When ratio corrected for lean mass, mice had a significant increase in energy expenditure, but more appropriate multiple linear regression normalisation showed no difference in energy expenditure. Global deletion of Fto after the in utero and perinatal period, at 6 weeks of age, removed the high lethality of germline loss. However, there was a reduction in weight by 9 weeks, primarily as loss of lean mass. Over the subsequent 10 weeks, weight converged, driven by an increase in fat mass. There was a switch to a lower RER with no overall change in food intake or energy expenditure. To test if the phenotype can be explained by loss of Fto in the mediobasal hypothalamus, we sterotactically injected adeno-associated viral vectors encoding Cre recombinase to cause regional deletion. We observed a small reduction in food intake and weight gain with no effect on energy expenditure or body composition. Thus, although hypothalamic Fto can impact feeding, the effect of loss of Fto on body composition is brought about by its actions at sites elsewhere. Our data suggest that Fto may have a critical role in the control of lean mass, independent of its effect on food intake.

The impact of hamstring lengthening on stance knee flexion at skeletal maturity in ambulatory cerebral palsy.

This study reports the long-term outcomes of hamstring lengthening to treat flexed knee gait in children with ambulatory cerebral palsy (CP) after skeletal maturity. This retrospective longitudinal observational study used instrumented gait analysis (GA) <8 and >15 years old in children with bilateral CP. The primary variable was knee flexion in stance phase. Eighty children (160 limbs) were included; 49% were male, 51% female. Mean age at first GA was 6.0 (SD: 1.2) years and 19.6 (SD: 4.5) years at final GA. Mean follow-up was 13.7 (SD: 4.7) years. Children were classified as Gross Motor Function Classification System I-8, II-46 and III-26. Average Gross Motor Function Measure Dimension D was 72% (SD: 20%). Hamstring lengthenings occurred once in 82, twice in 54 and three times in 10 limbs. From initial to final GA, average knee flexion in stance was unchanged, 27.8° (SD: 14.8°) to final 27.0° (SD: 11.2°; P = 0.54). Knee flexion at foot contact was 39.6° (SD: 13.0°), improving to final GA of 30.7° (SD: 10.6°; P < 0.001). Initial gait deviation index was 65.8 (SD: 31.9), improving to final 78.9 (SD: 28.2; P < 0.001). Older age, males and concomitant plantar flexor lengthening predicted change toward more flexed knee gait. Hamstring lengthening did not lead to back-kneeing gait at maturity while maintaining childhood stance phase knee flexion. A subgroup still developed significant flexed knee gait posture and may have benefited from more aggressive treatment options. This outcome may also be impacted by diverse functional levels, etiologies and treatments of flexed knee gait.

Changes in foot posture evaluated with dynamic pedobarography over the course of childhood in ambulatory youth with cerebral palsy.

Purpose: Foot deformities are prevalent in children with cerebral palsy, but there is limited research on the progression of foot posture during growth. Our study aimed to evaluate the change in dynamic foot posture in children with cerebral palsy. Methods: Children with cerebral palsy, aged 17-40 months, were recruited to participate in this Institutional Review Board-approved prospective longitudinal study by having serial foot posture evaluations. The coronal plane index and foot segmental impulses were measured with dynamic pedobarography. Data were compared between children stratified by Gross Motor Function Classification System level and typically developing children using serial Welch's t-tests across time with Holm correction for multiple comparisons. Results: In total, 33 children (54 limbs) were included in the analysis (21 bilateral and 12 unilateral; Gross Motor Function Classification System: I-13, II-14, III-4, IV-2. Children completed 16.9 (± 4.4) evaluations (initial age 2.9 (± 0.7) and final age 18.6 (± 1.7) years)). Early valgus foot posture normalizes in children at Gross Motor Function Classification System levels I/II and persists in children at levels III/IV who do not have foot surgery. For most young children, foot posture development is variable. Conclusion: Foot posture in young children with cerebral palsy begins in valgus and tends to normalize in youth who walk without an assistive device. Conservative management of foot deformity is recommended in early childhood. Level of evidence: Level II, prognostic study.