Can early subclinical gait changes in children with haemophilia be identified using the GAITRite�walkway

Adolescents with hemophilic knee arthropathy can improve their gait characteristics, functional ability, and physical activity level through kinect-based virtual reality: A randomized clinical trial

Background

Hemophilic arthropathy is caused by recurrent intra-articular bleeding, most commonly in the knee joints. In terms of physical impact, this arthropathy causes significant disability and hampers the physical activity and functionality of he affected individuals.

Objective

This study intended to examine the effect of a physical rehabilitation program incorporating Kinect-based virtual reality (KBVR) on gait characteristics, functional ability, and physical activity level in adolescents diagnosed with hemophilic knee arthropathy (HKA).

Materials and methods

In a randomized clinical trial, 56 boys, aged 10-14 years, with moderate HKA, were randomly allocated into two groups. The control group (n = 28) received conventional physical therapy (CPT), while the KBVR group (n = 52) received a 30-min KBVR exercise program in addition to the CPT. Training was conducted three times/week for 12 successive weeks. Gait characteristics (step length, cadence, velocity, peak knee extension moment during stance, and knee flexion amplitude during swing) were assessed using a gait analysis system, the functional ability was assessed through the 6-min walk test, and physical activity level assessed by the Adolescents' Physical Activity Questionnaire on the pre- and post-treatment occasions.

Results

The KBVR group achieved more favorable changes in the gait characteristics [step length (P = 0.015), cadence (P = 0.004), velocity (P = 0.024), peak knee extension moment during stance (P = 0.018), and Knee flexion amplitude during swing (P = 0.032)], functional capacity (P = 0.002), and physical activity levels (P = 0.007) compared to the control group.

Conclusion

The use of KBVR exercises within a rehabilitation program is a potentially effective therapeutic option for the total care of adolescents with HKA.

Hopping as an Indicator of Chemotoxicity: Gait Analysis in Patients With Leukemia and Lymphoma

BACKGROUND

Survivors of acute lymphoblastic leukemia (ALL) can experience chemotherapy-related changes in neuromuscular function, which can persist and impact the quality of life. Clinically, neuromuscular changes are assessed by observing gait. The primary aims of this study were to compare observational gait/functional movement analysis to matched electronic gait analysis in children with ALL and lymphoblastic lymphoma at specific time points during and after treatment.

PATIENTS AND METHODS

Participants 2 to 27 years old diagnosed with ALL/lymphoblastic lymphoma who were on or off therapy within 10 years were eligible. Participants underwent electronic gait assessment using GAITRite, observational gait, and functional movement analysis and completed quality of life questionnaires. Parents also completed quality-of-life assessments.

RESULTS

Electronic gait parameters were not different in this cohort compared with controls. Mean overall scores on observational gait and functional movement analysis improved over time. Hopping was the most frequent and walking was the least frequent noted deficit. Participants had a lower patient and parent-reported QoL scores compared with the general population.

CONCLUSION

Observational gait and functional movement analysis identified more deficits than the electronic gait assessment. Future studies are warranted to determine whether hopping deficits are an early clinical indicator of toxicity and signal for intervention.

Postural Assessment Systems in the Prevention of Haemophilic Arthropathy: A Narrative Review

This narrative review aims to give an overview of some postural evaluation systems currently used in patients with haemophilia. Among them, first, we analyse the HJHS scale, recognized as a specific evaluation tool for haemophilic arthropathy. Second, we focus on other systems usually used in non-haemophilic patients that have also shown good applicability in this patient category, such as gait analysis, stabilometry, and baropodometric examination. This review underlines the use these tools could have in clinical practice to identify the early postural alterations in patients with haemophilia and set up personalised rehabilitation programs.

Gait Alteration Due to Haemophilic Arthropathies in Patients with Moderate Haemophilia

Some patients with moderate haemophilia (PWMH) report joint damage potentially responsible for gait disorders. Three-dimensional gait analysis (3DGA) is a relevant tool for the identification of complex musculoskeletal impairment. We performed an evaluation with 3DGA of 24 PWMH aged 44.3 ± 16.1 according to their joint status [Haemophilia Joint Health Score (HJHS) < 10 or HJHS ≥ 10] and assessed the correlation with the radiological and clinical parameters. Sixteen had HJHS < 10 (group 1) and eight had HJHS ≥ 10 (group 2). They were compared to 30 healthy subjects of a normative dataset. Both knee and ankle gait variable scores were increased in group 2 compared to the controls (p = 0.02 and p = 0.04, respectively). The PWMH of group 2 had a significant increase in their stance phase, double support duration, and stride width compared to the controls and group 1 (p < 0.01). Very low correlations were found for the ankle gait variable score with the ankle Pettersson sub-score (r2 = 0.250; p = 0.004) and ankle HJHS sub-score (r2 = 0.150; p = 0.04). For the knee, very low correlation was also found between the knee gait variable score and its HJHS sub-score (r2 = 0.290; p < 0.0001). Patients with moderate haemophilia presented a gait alteration in the case of poor lower limb joint status.

Biomechanical Gait Analysis of an Adult with Severe Hemophilia: A Case Report

Hemophilia is characterized by recurrent bleeding into the joints leading to irreversible chronic arthropathy with reduced joint range of motion (ROM), which may lead to changes in gait patterns. To analyze the gait pattern in a 35-year-old male with severe hemophilia A, three-dimensional biomechanical analysis was performed during overground walking. The control group data from a public gait dataset of 10 healthy male individuals were used for comparison. The clinical examination was assessed with the Functional Independence Score in Hemophilia (FISH), Haemophilia Activities List (HAL), and Hemophilia Joint Health Score (HJHS). The biomechanical analysis demonstrated a pattern for both left knee and ankle joints with greater similarity to the control group compared to the right knee and ankle joints. ROM based on the HJHS questionnaire also showed greater impairment of the right-side knee joint compared to the left-side knee joint. This unique pattern could be the result of a compensation mechanism due to limited movement during the walking task and the surgical treatment.

The effect of age on the pressure pain threshold of asymptomatic ankles and knees in young individuals with haemophilia

INTRODUCTION

Despite adequate medical treatment, many young adults with haemophilia develop joint alterations-especially in ankles and knees. Undetected over years, subtle structural changes cause subclinical symptoms, before problems become obvious. To objectify these silent pressure pains, the pressure pain threshold (PPT) can be measured by algometry.

AIM

The aim was to investigate and compare the effect of age on PPTs in asymptomatic ankles and knees between boys and young adults with haemophilia and age-matched controls, in order to gain better knowledge about the alteration of the periarticular structures with increasing age.

MATERIAL AND METHODS

Nineteen persons with haemophilia (PwH; severe or moderate; 8-30 years) and 19 age-matched controls with 'healthy' ankles and knees were recruited. Asymptomatic joints with a Haemophilia Joint Health Score = 0 were included. The PPT was measured on four periarticular points per joint, and the data were analysed with a linear mixed model.

RESULTS

The PPT of the control group increased with age, whereas the PPT of the PwH decreased. The difference in age effect per year in kPa between PwH and controls was as follows: β [95%-CI]: -15.41 [-31.63; 0.79]. Although the result was not statistically significant (p = .08), a clear tendency was shown.

CONCLUSION

The results suggest that subclinical alterations in the periarticular structures of these joints may evolve unnoticed over time. However, further research is warranted to determine whether this observed trend is confirmed in a larger sample and at what age the PPT begins to decrease in PwH compared to controls.

The Progression of Hemophilic Arthropathy: The Role of Biomarkers

BACKGROUND

Hemophilia A and B are X-linked congenital bleeding disorders characterized by recurrent hemarthroses leading to specific changes in the synovium and cartilage, which finally result in the destruction of the joint: this process is called hemophilic arthropathy (HA). This review highlights the most prominent molecular biomarkers found in the literature to discuss their potential use in the clinical practice to monitor bleeding, to assess the progression of the HA and the effectiveness of treatments.

METHODS

A review of the literature was performed on PubMed and Embase, from 3 to 7 August 2020. Study selection and data extraction were achieved independently by two authors and the following inclusion criteria were determined a priori: English language, available full text and articles published in peer-reviewed journal. In addition, further articles were identified by checking the bibliography of relevant articles and searching for the studies cited in all the articles examined.

RESULTS

Eligible studies obtained at the end of the search and screen process were seventy-three (73).

CONCLUSIONS

Despite the surge of interest in the clinical use of biomarkers, current literature underlines the lack of their standardization and their potential use in the clinical practice preserving the role of physical examination and imaging in early diagnosis.

Age-related gait standards for healthy children and young people: the GOS-ICH paediatric gait centiles

OBJECTIVE

To develop paediatric gait standards in healthy children and young people.

METHODS

This observational study aims to address the lack of population standards for gait measurements in children. Analysing gait in children affected by neurological or musculoskeletal conditions is an important component of paediatric assessment but is often confounded by developmental changes. The standards presented here do not require clinician expertise to interpret and offer an alternative to developmental tables of normalised gait data. Healthy children aged 1-19 years were recruited from community settings in London and Hertfordshire, UK. The GAITRite walkway was used to record measurements for each child for velocity, cadence, step length, base of support and stance, single and double support (as percentage of gait cycle). We fitted generalised linear additive models for location, scale and shape (gamlss).

RESULTS

We constructed percentile charts for seven gait variables measured on 624 (321 males) contemporary healthy children using a gamlss package in R. A clinical application of gait standards was explored.

CONCLUSION

Age-related, gender-specific standards for seven gait variables were developed and are presented here. They have a familiar format and can be used clinically to aid diagnoses and to monitor change over time for both medical therapy and natural history of the condition. The clinical example demonstrates the potential of the Great Ormond Street Institute of Child Health Paediatric Gait Centiles to enable meaningful interpretation of change in an individual's performance and describes characteristic features of gait from a specific population throughout childhood.

Evaluating the Sensoria Smart Socks Gait Monitoring System for Rehabilitation Outcomes

BACKGROUND

Gait monitoring is important for rehabilitation but clinic-based measurements provide a brief snapshot of gait patterns. Many consumer-based activity monitors facilitate continuous gait monitoring in daily life but may be subject to measurement errors. This study examines a novel consumer-based activity monitor that is worn on the feet, and therefore not susceptible to inaccurately detecting upper body movements as gait.

OBJECTIVE

To evaluate the clinical validity of Sensoria smart socks, a commercially available wireless gait monitoring technology.

DESIGN

A method comparison study between the GAITRite, a criterion standard for clinical gait monitoring, and Sensoria smart socks.

SETTING

Outpatient rehabilitation clinic.

PARTICIPANTS

Thirty individuals capable of supervised ambulation, with or without assistive devices, were recruited through the use of flyers and emails. Data were analyzed for 29 participants. Fifteen participants had no neurologic diagnosis. Fourteen participants had a neurologic diagnosis that could result in gait impairments. Diagnoses included Parkinson disease, stroke, brain injury, developmental delay, and acoustic neuroma.

METHODS

Participants completed three gait trials with simultaneous measurements by the smart socks and the GAITRite.

MAIN OUTCOME MEASURES

Measurements of step count, cadence, and velocity were compared between the two gait monitoring systems.

RESULTS

There was no significant difference in step count measurements between the two systems. Although there was a significant difference in cadence measurements for the total sample group, the mean difference fell within the GAITRite Standard Error of Measurement. There was no significant difference in velocity measurements for the total sample group and the mean difference fell within the GAITRite Standard Error of Measurement.

CONCLUSION

These results support the clinical validity of the smart socks for measuring step number and velocity. Further investigation is warranted to determine the efficacy and clinical value of the smart socks system for measuring cadence and for monitoring gait over longer distances outside the clinic.

LEVEL OF EVIDENCE

III.

Physiotherapy Treatments in Musculoskeletal Pathologies Associated with Haemophilia

The aim of this study is to offer physiotherapists a synthesis of the main therapeutic tools available for the treatment of musculoskeletal pathologies in patients with haemophilia, according to the scientific literature. Although bleeds are recognised as no longer being a cause of death for people with haemophilia, the accompanying musculoskeletal injuries now represent the main problem associated with this disorder. There is a lack of clear guidelines to date regarding the physiotherapy treatment of these disorders. We performed a keyword searches of Pubmed, Scopus, Sciencedirect, Cochrane and PEDro databases. In total, 555 references were retrieved, of which only 55 fulfilled the inclusion criteria. Publications were grouped by the main symptoms caused by haemophilia and the physiotherapy treatments available. The literature reviewed shows that physiotherapists have a range of therapeutic tools at their disposal for the treatment of the main musculoskeletal disorders suffered by patients with haemophilia. Physiotherapy interventions act upon inflammation and pain, as well as favouring the reabsorption of haematomas, preventing muscle fibrosis and joint ankylosis and recovering the joint range from prior to the lesions. Also, these interventions help prevent muscle atrophy and provide patients with the optimal physical conditions for facing the small and repetitive injuries that, over time, can have a detrimental effect on their quality of life.

CONCLUSION

Haemophilic patients suffer from a series of musculoskeletal disorders, which are associated with important functional disability. Physiotherapy and adapted sports are essential for decreasing disability and improving the quality of life of affected patients.

Recent advances in musculoskeletal physiotherapy for haemophilia

Physiotherapy is directed towards the movement needs and potential of individuals, providing treatment and rehabilitation to develop, maintain and restore maximum movement and functional ability throughout the lifespan. Recent systematic reviews and randomized controlled trials have extended evidence for the clinical efficacy of physiotherapy interventions and rehabilitation for people with haemophilia. This narrative review synthesizes recent evidence to discuss; differentiating musculoskeletal bleeding and haemophilic arthropathy, efficacy of physiotherapy and rehabilitation for acute musculoskeletal bleeding and arthropathy, as well as monitoring musculoskeletal health. Whilst robust evidence is emerging, there is a need for more well designed randomized clinical studies with larger numbers and homogeneity of participants and collaboration of all researchers and clinicians to identify a core set of outcome measures that can be used to monitor musculoskeletal health.

Evaluating the immediate effects of wearing foot orthotics in children with Joint Hypermobility Syndrome (JHS) by analysis of temperospatial parameters of gait and dynamic balance: A preliminary study

Joint Hypermobility Syndrome (JHS) in children, presents with increased joint range of motion and can lead to altered gait strategies and reduced dynamic balance. Despite limited evidence foot orthoses are sometimes prescribed to patients with JHS with the aim to improve the stability of their gait pattern and theoretically reduce associated symptoms of fatigue and joint pain. The purpose of this study was therefore to analyse the immediate effects of 'off the shelf' orthoses on temporospatial parameters of gait and dynamic balance in this cohort.

METHODS

A total of 21 patients were recruited for the study (13 female) with a median age of 10 years (IRQ = 4.12). Each patient had their gait analysed using the GAITRite walkway in their own footwear and immediately after being prescribed the orthoses. Gait was tested at both the patients' preferred speed and when asked to walk slower to challenge their dynamic balance.

RESULTS

Gait appeared more synchronised, with a reduction in step length and width variability, when participants were provided with orthotics. The variation was greatest when participants were asked to walk slower. Double stance was significantly less at slower speeds when orthotics were added (1.61%, 95% CI = 0.34, 2.89, p = 0.015) CONCLUSION: Results of this study indicate that orthotics have a definite immediate influence on gait patterns in patients with JHS. Future studies should investigate the long-term effects of orthotics in this population and include outcome measures for symptoms such as pain.

Classification of Normal and Pathological Gait in Young Children Based on Foot Pressure Data

Human gait recognition, an active research topic in computer vision, is generally based on data obtained from images/videos. We applied computer vision technology to classify pathology-related changes in gait in young children using a foot-pressure database collected using the GAITRite walkway system. As foot positioning changes with children's development, we also investigated the possibility of age estimation based on this data. Our results demonstrate that the data collected by the GAITRite system can be used for normal/pathological gait classification. Combining age information and normal/pathological gait classification increases the accuracy of the classifier. This novel approach could support the development of an accurate, real-time, and economic measure of gait abnormalities in children, able to provide important feedback to clinicians regarding the effect of rehabilitation interventions, and to support targeted treatment modifications.

A comparison of two types of ankle supports in men with haemophilia and unilateral ankle pain from arthropathy

INTRODUCTION

Adults with haemophilia frequently have a painful and disordered gait due to ankle arthropathy.

AIM

The aim of this study was to determine if pain and gait parameters were affected by the use of different types of ankle bracing.

METHODS

We investigated the gait patterns of 17 men with severe haemophilia without bracing, using a fracture boot (FB) and a carbon fibre floor reaction ankle foot orthosis (CF-AFO). Pain relief was determined in each condition. Gait parameters were measured by means of an electronic, pressure sensitive mat.

RESULTS

Both brace types relieved pain. Use of a FB altered gait parameters that are associated with movement of the involved and the uninvolved limb during the gait cycle, whereas the use of a CF-AFO did not affect the gait cycle.

CONCLUSION

This study suggests that pain relief from both types of braces is identical but use of a CF-AFO does not alter gait patterns.

Effects of 3,3',5-triiodothyronine on microglial functions

L-tri-iodothyronine (3, 3', 5-triiodothyronine; T3) is an active form of the thyroid hormone (TH) essential for the development and function of the CNS. Though nongenomic effect of TH, its plasma membrane-bound receptor, and its signaling has been identified, precise function in each cell type of the CNS remained to be investigated. Clearance of cell debris and apoptotic cells by microglia phagocytosis is a critical step for the restoration of damaged neuron-glia networks. Here we report nongenomic effects of T3 on microglial functions. Exposure to T3 increased migration, membrane ruffling and phagocytosis of primary cultured mouse microglia. Injection of T3 together with stab wound attracted more microglia to the lesion site in vivo. Blocking TH transporters and receptors (TRs) or TRα-knock-out (KO) suppressed T3-induced microglial migration and morphological change. The T3-induced microglial migration or membrane ruffling was attenuated by inhibiting Gi /o -protein as well as NO synthase, and subsequent signaling such as phosphoinositide 3-kinase (PI3K), mitogen-activated protein kinase (MAPK)/extracellular signal-regulated kinase (ERK). Inhibitors for Na(+) /K(+) -ATPase, reverse mode of Na(+) /Ca(2+) exchanger (NCX), and small-conductance Ca(2+) -dependent K(+) (SK) channel also attenuated microglial migration or phagocytosis. Interestingly, T3-induced microglial migration, but not phagocytosis, was dependent on GABAA and GABAB receptors, though GABA itself did not affect migratory aptitude. Our results demonstrate that T3 modulates multiple functional responses of microglia via multiple complex mechanisms, which may contribute to physiological and/or pathophysiological functions of the CNS.

Relationship between cognitive dysfunction, gait, and motor impairment in children and adolescents with neurofibromatosis type 1

AIM

Motor skill impairment and cognitive dysfunction are commonly reported features of neurofibromatosis type 1 (NF1). We characterized and determined the relationship between motor impairment, gait variables, and cognitive function in children and adolescents with NF1.

METHOD

Motor function, gait, and neurocognitive abilities were assessed in 46 children and adolescents with NF1 (26 males, 20 females; age range 7-17 y; mean age 11 y 1 mo, SD 3 y 2 mo). Tests to establish correlations between neurocognitive, motor, and gait variables were performed.

RESULTS

Compared with normative data, 28/39 of our NF1 cohort demonstrated impaired performance for balance and upper limb coordination and 16/38 for running speed and agility. Gait data revealed a strategy to preserve balance at the expense of velocity, with the unexpected exception of a tendency for reduced base of support. Neurocognitive testing confirmed mean IQ in the low average range (86.0) and deficits in spatial working memory and strategy generation. Significant correlations between a number of neurocognitive measures and motor abilities and gait were identified. The largest associations were between gait width and spatial working memory (r=0.594) and running speed and agility with strategy generation (r=0.549).

INTERPRETATION

We have identified a relationship between balance, running speed and agility, gait, and cognition in children with NF1. Findings suggest a shared abnormal neurodevelopmental process underlying some cognitive and motor abilities in NF1. Results are discussed within the context of evidence highlighting abnormal dopamine-mediated corticostriatal circuitry in NF1.

Early orthopaedic challenges in haemophilia patients and therapeutic approach

INTRODUCTION

There is growing evidence that subclinical joint bleeding early in life may lead to subtle changes in joint function, gait, and muscle development in young children with haemophilia. The early identification of such changes provides an opportunity for clinicians to intervene before irreversible structural changes occur.

MATERIALS AND METHODS

We have undertaken motion analysis of the knee in 273 children (mean age 9.8 years) with haemophilia A, haemophilia B, or von Willebrand disease and compared the results with those from 200 healthy age- and sex-matched controls (mean age 10.3 years). We have also completed detailed orthopaedic assessments and evaluated overall fitness in most of these children.

RESULTS

There was a clear correlation between total motion score and age: r(2)=0.47 for the healthy children and r(2)=0.69 for the haemophilic children. The differences were most striking in children aged 3-4 years. Significant between-group differences were also observed in the comparison of knee bends, gait scores, and rhythmicity. Orthopaedic examinations revealed previously clinically silent pressure pains in the ligaments of the knee joints of 38% of children and in the ligaments and capsule of the ankle joints of 60% of children. The five-item fitness check showed significant deficits relative to controls in overall fitness, endurance, coordination, and flexibility.

CONCLUSIONS

Children and adolescents with haemophilia show significant functional impairments relative to normal controls. Early comprehensive assessments of the musculoskeletal system should be made so that individualized physical, physiotherapy, and sports therapy programmes can be developed.

Outcome measures monitoring physical function in children with haemophilia: a systematic review

Our objective was to provide a synthesis of measurement properties for performance-based outcome measures used to evaluate physical function in children with haemophilia. A systematic review of articles published in English using Medline, PEDro, Cinahl and The Cochrane Library electronic databases was conducted. Studies were included if a performance-based method, clinical evaluation or measurement tool was used to record an aspect of physical function in patients with haemophilia aged ≤ 18 years. Recording of self-perceived or patient-reported physical performance, abstracts, unpublished reports, case series reports and studies where the outcome measure was not documented or cross-referenced was excluded. Description of outcome measures, patient characteristics, measurement properties for construct validity, internal consistency, repeatability, responsiveness and feasibility was extracted. Data synthesis of 41 studies evaluating 14 measures is reported. None of the outcome measures demonstrated the requirements for all the measurement properties. Data on validity and test-retest repeatability were most lacking together with studies of sufficient size. Measurement of walking and muscle strength demonstrated good repeatability and discriminative properties; however, correlation with other measures of musculoskeletal impairment requires investigation. The Haemophilia Joint Health Score demonstrated acceptable construct validity, internal consistency and repeatability, but the ability to discriminate changes in physical function is still to be determined. Rigorous evaluation of the measurement properties of performance-based outcome measures used to monitor physical function of children with haemophilia in larger collaborative studies is required.

Repeated autologous intraarticular blood injections as an animal model for joint pain in haemophilic arthropathy

Introduction

Haemophilic arthropathy following recurrent joint bleedings is one of the major disease-related complications in people with haemophilia (PWH), leading to mostly chronic joint pain. Since many antinociceptive principles interfere with the clotting system, PWH are restricted in treatment options, thereby defining a medical need for novel therapeutic principles. However, we lack the availability of an animal model for joint pain in haemophilic arthropathy for testing these.

Methods

In this study, we aimed to validate the rat model of repeated autologous intraarticular blood injections specifically for pain-related behavior. During an observation period of 50 days, groups of animals were injected weekly into one knee joint with either whole blood or cellular/plasma components.

Results

Injections induced primary hyperalgesia starting after the third injection, accompanied by mild functional gait changes and joint swelling. Secondary hyperalgesia and quantitative gait disturbances were not observed. This phenotype was most prominent in whole blood injected animals, with effect sizes of cells and plasma being additive. In order to differentiate haemophilia-related arthropathy from traumatic joint bleeding, another group was injected with whole blood only once, which did not cause any alterations.

Conclusions

Repeated autologous intraarticular injections of blood showed a time course, inflammatory response and reduction in pain thresholds similar to the signs and symptoms observed in PWH. Therefore, this model may be utilised in the future for testing novel antinociceptive principles in haemophilia-associated joint pain.

The effect of neutral-cushioned running shoes on the intra-articular force in the haemophilic ankle

BACKGROUND

The ankle continues to be one of the most affected joints in the haemophilia patient, and as cartilage damage progresses, the joint can feel unstable, painful and stiff. Anecdotally, patients often report that sports trainers can improve their pain and daily function, however the actual mechanism for this remains unclear.

METHODS

Nine patients with ankle haemarthropathy and three controls were examined using 'CODAmotion' analysis and a force plate. Kinematic and kinetic variables of the hip, knee and ankle were recorded. Data was imported from CODA to Excel, where a programme using 2D modelling of the ankle joint forces was employed. This calculated intra-articular force from heel strike to toe-off.

FINDINGS

The haemophilia group at midstance showed an increase in intra-articular force in the ankle when wearing the trainer compared to the shoe (P=<0.05). Overall the haemophilia cohort had an increased joint force in both the trainers and shoes, compared to controls.

INTERPRETATION

The type of footwear worn by individuals with ankle arthropathy has a significant effect on the amount of force acting at the joint surface. Sports shoes, in providing better comfort and foot support, may facilitate an increased muscular activity around the ankle and therefore improved dynamic joint stability, accounting for why some patients with ankle arthropathy report less pain. Further research is needed to establish levels of acceptable force and the combined effects of orthotics and footwear.

Biomechanics of lower limb haemophilic arthropathy

Intermittent joint bleeding and potential arthropathy remain a concern for patients and those responsible for haemophilic care. Monitoring the status of haemophilic joints is a current challenge. Evaluation of bone and soft tissue with radiological imaging together with clinical joint scoring is often used to monitor haemophilic arthropathy and may not be sufficiently sensitive to early changes in joint morphology. Recently an interest in the biomechanical status of haemophilic joints has emerged. Biomechanics is defined as the interdiscipline that describes, analyses and assesses movement in relation to biological and physical principles. This review considers the biomechanical evaluation of haemophilic joint status of the lower limb with particular reference to the evaluation of muscle atrophy, muscle strength, range of motion and gait as well as the relationship to haemophilic arthropathy. In raising the need for increased clinical awareness, this review highlights the need to establish test-retest and inter-rater reliability and ensuring that comparative studies are undertaken with age-matched unaffected peer groups.

Joint health and functional ability in children with haemophilia who receive intensive replacement therapy

Joint physical examination is an important outcome in haemophilia; however its relationship with functional ability is not well established in children with intensive replacement therapy. Boys aged 4-16 years were recruited from two European and three North American treatment centres. Joint physical structure and function was measured with the Haemophilia Joint Health Score (HJHS) while functional ability was measured with the revised Childhood Health Assessment Questionnaire (CHAQ₃₈. Two haemophilia-specific domains were created by selecting items of the CHAQ₃₈ that cover haemophilia-specific problems. Associations between CHAQ, HJHS, cumulative number of haemarthroses and age were assessed. A total of 226 subjects - mean 10.8 years old (SD 3.8) - participated; the majority (68%) had severe haemophilia. Most severe patients (91%) were on prophylactic treatment. Lifetime number of haemarthroses [median=5; interquartile range (IQR)=1-12] and total HJHS (median = 5; IQR=1-12) correlated strongly (ρ = 0.51). Total HJHS did not correlate with age and only weakly (ρ=-0.19) with functional ability scores (median=0; IQR=-0.06-0). Overall, haemarthroses were reported most frequently in the ankles. Detailed analysis of ankle joint health scores revealed moderate associations (ρ=0.3-0.5) of strength, gait and atrophy with lower extremity tasks (e.g. stair climbing). In this population, HJHS summating six joints did not perform as well as individual joint scores, however, certain elements of ankle impairment, specifically muscle strength, atrophy and gait associated significantly with functional loss in lower extremity activities. Mild abnormalities in ankle assessment by HJHS may lead to functional loss. Therefore, ankle joints may warrant special attention in the follow up of these children.

Validation of a new pediatric joint scoring system from the International Hemophilia Prophylaxis Study Group: validity of the hemophilia joint health score

OBJECTIVE

Repeated hemarthrosis in hemophilia causes arthropathy with pain and dysfunction. The Hemophilia Joint Health Score (HJHS) was developed to be more sensitive for detecting arthropathy than the World Federation of Hemophilia (WFH) physical examination scale, especially for children and those using factor prophylaxis. The HJHS has been shown to be highly reliable. We compared its validity and sensitivity to the WFH scale.

METHODS

We studied 226 boys with mild, moderate, and severe hemophilia at 5 centers. The HJHS was scored by trained physiotherapists. Study physicians at each site blindly determined individual and total joint scores using a series of visual analog scales.

RESULTS

The mean age was 10.8 years. Sixty-eight percent were severe (93% of whom were treated with prophylaxis), 15% were moderate (24% treated with prophylaxis), and 17% were mild (3% treated with prophylaxis). The HJHS correlated moderately with the physician total joint score (rs=0.42, P<0.0001) and with overall arthropathy impact (rs=0.42, P<0.0001). The HJHS was 97% more efficient than the WFH at differentiating severe from mild and moderate hemophilia. The HJHS was 74% more efficient than the WFH at differentiating subjects treated with prophylaxis from those treated on demand. We identified items on the HJHS that may be redundant or rarely endorsed and could be removed from future versions.

CONCLUSION

Both the HJHS and WFH showed evidence of strong construct validity. The HJHS is somewhat more sensitive for mild arthropathy; its use should be considered for studies of children receiving prophylaxis.

Changes in gait pattern as assessed by the GAITRite™ walkway system in MPS II patients undergoing enzyme replacement therapy

Patients with MPS II often present with limitations to functional mobility. With the advent of enzyme replacement therapy (ERT), robust assessment tools are important to assess response to treatment. The aim of this study was to see if the GAITRite™ system (electronic pressure sensitive walkway) could identify any changes to gait pattern following commencement of ERT. Six boys with MPS type II were assessed at baseline and at intervals post commencing ERT. Four individual characteristics of gait were studied - velocity, cadence, step length and base of support. Changes in parameters for each individual could be analysed and be compared with age matched controls. The data generated from the GAITRite™ indicated all six boys had changes to their gait pattern. The most notable changes were in velocity, step length and base of support. The GAITRite™ was found to identify changes in gait parameters in this group of patients. It is an accessible way of providing both quantitative and qualitative analysis of gait in the clinical environment, and could potentially be used to monitor response to treatment. Larger studies are needed to corroborate our findings, as well as to establish the GAITRite™ as a monitoring tool.

Evolution of foot and ankle manifestations in children with CMT1A

We studied the timing and progression of foot and ankle changes in 81 children with genetically confirmed Charcot-Marie-Tooth disease type 1A (CMT1A) and determined their impact on motor function and walking ability. Foot deformity, weakness, pain, cramps, and instability were a common feature of CMT1A. Foot structure evolved toward pes cavus from early childhood to adolescence, although a subgroup with normal and planus feet remained. Foot strength increased with age, although compared to age-equivalent norms it declined from 4 years. Factors associated with evolving foot deformity included muscle weakness/imbalance, restricted ankle flexibility, and joint hypermobility. Regression modeling identified dorsiflexion weakness, global foot weakness, and difficulty toe-walking as independent predictors of motor dysfunction, while pes cavus and difficulty heel-walking were predictors of poor walking ability. Foot problems are present from the earliest stages of the disease and can have a negative impact on function. Early foot and ankle intervention may prevent long-term disability and morbidity in CMT1A.