Effect of Body Mass Index on Pedobarographic and Patient-Reported Outcome Measures in Adolescent Flexible Flat Feet

BACKGROUND

Although adolescent flexible flatfoot deformity (FFD) is common, little is known regarding the effect of weight on associated symptomatology. This study uses pedobarography and patient-reported outcome measures (PROs) to determine if overweight adolescents with FFD have more severe alterations in dynamic plantar pressures than normal body mass index percentiles (wnBMI) with FFD and if such alterations correlate with pain and activity.

METHODS

A retrospective review of patients aged 10 to 18 years with nonsyndromic symptomatic FFD was performed. Overweight (BMI percentile ≥ 85%) patients were compared with wnBMI patients with regard to dynamic plantar pressure measures and PRO scores. Pedobarographic data were subdivided into regions: medial/lateral hindfoot and midfoot, and first, second, and third to fifth metatarsals. Plantar pressure variables were normalized to account for differences in foot size, body weight, and walking speed. Contact area (CA%), maximum force by body weight (MF%), and contact time as a percentage of the rollover process (CT%) were calculated. Two foot-specific PROs were assessed, including the Foot and Ankle Outcome Score and the Oxford Ankle Foot Measure for Children.

RESULTS

Of the 48 adolescents studied, 27 (56%) were overweight and 21 (44%) were wnBMI. After normalization of the data, overweight patients had significantly greater medial midfoot MF%, whereas CT% was increased across the medial and lateral midfoot and hindfoot regions. Correlations showed positive trends: as BMI percentile increases, so will CA and MF in the medial midfoot, as well as CT in the medial and lateral midfoot and hindfoot. Significant differences were seen between groups, with the overweight group reporting lower sports and recreation subscores than the wnBMI group. No significant differences were seen in the pain and disability subscores.

CONCLUSIONS

Although overweight adolescents with FFD exhibit greater forces and more time spent during the rollover process in the medial midfoot than normal-weight patients, they did not report worse pain or disability associated with their flat foot deformity.

LEVEL OF EVIDENCE

Therapeutic level 3.

Investigating pelvic drop gait abnormality in adolescent hip pathology patients

BACKGROUND

Trendelenburg gait describes contralateral pelvic drop during single leg stance (SLS) with occasional lateral trunk lean compensation over the stance limb. However, quantitative research on 'uncompensated Trendelenburg' gait (pelvic drop independent of lateral trunk lean) remains sparse among populations that commonly utilize this gait pattern, such as adolescent hip pathology patients.

RESEARCH QUESTION

How prevalent is uncompensated Trendelenburg among various adolescent hip pathologies and how is it related to hip load, hip abduction strength, and self-reported hip pain?

METHODS

Gait, strength, and pain data were collected among 152 pre-operative patients clinically diagnosed with acetabular hip dysplasia, femoroacetabular impingement, Legg-Calvé-Perthes, or slipped capital femoral epiphysis (SCFE). Patients with ≥ 5.4° of dynamic pelvic drop in SLS were divided into a 'pelvic drop' group and screened to exclude those with excessive ipsilateral trunk lean. They were then compared to the 'stable pelvis' patients using a Mann-Whitney test.

RESULTS

Dysplasia patients represented the highest proportion of the pelvic drop group (46%). The pelvic drop group showed a significant increase in self-reported hip pain (p = 0.011), maximum hip abductor moment (p = 0.002), and peak coronal power absorption at the affected hip during SLS loading response, (p < 0.001) while showing no difference in abduction strength (p = 0.381).

SIGNIFICANCE

Uncompensated Trendelenburg gait may lead to increased loading of the affected hip in adolescent hip pathology patients. Disadvantageous hip biomechanics can create increased abductor muscle demand among these pathological populations, with dysplasia patients showing the highest prevalence. Maximal abduction strength did not correlate with pelvic drop. Future work should aim to identify and quantify causal factors. Increased coronal hip power absorption during weight acceptance warrants clinical attention, as there may be a detrimental, over-reliance on passive hip structures to support load among a population that that is already predisposed to hip osteoarthritis.

Normative dataset selection affects gait profile scores of children with cerebral palsy

INTRODUCTION

The Gait Profile Score (GPS) requires a comparative dataset, to identify altered mechanics in persons with a gait abnormality. This gait index has been shown to be useful for identifying gait pathology prior to the assessment of treatment outcomes. Though studies have shown differences in kinematic normative datasets between different testing sites, there is limited information available on the changes in GPS score based on normative dataset selection. The aim of this study was to quantify the influence of normative reference data from two institutions, on the GPS and Gait Variable Scores (GVS), calculated on the same group of patients with Cerebral Palsy.

METHODS

Seventy patients (Avg. age: 12.1 ± 2.9) diagnosed with CP underwent gait analysis during walking at a self-selected speed at Scottish Rite for Children (SRC). GPS and GVS scores were determined using normative kinematic data at a self-selected speed from, 83 typically developing children ages 4-17 from Gillette, and the same age range of children from SRC's normative dataset. Average normalized speed was compared between institutions. Signed rank tests were performed on the GPS and GVS scores using each institution's dataset. Spearman's correlations between scores using SRC and Gillette were determined within GMFCS level.

RESULTS

Normalized speed was comparable between each institution's datasets. Within each GMFCS level, significant differences when using SRC vs. Gillette were found in most scores (p < 0.05). Scores were moderately to strongly correlated within each GMFCS level (range ρ = 0.448-0.998).

CONCLUSIONS

Significant statistical differences were found in GPS and GVS scores but were within the range of previously reported variation across multiple sites. Caution and consideration may need to be taken when reporting GPS and GVS scores that are calculated utilizing different normative datasets as these scores may not be equivalent.

Inclusive community playgrounds benefit typically developing children: An objective analysis of physical activity

Purpose

Limited research is available on the physical activity levels of children while playing on an inclusive playground, specifically designed to accommodate children with physical disabilities. The aims of this study were to objectively measure ambulatory activity and heart rate (HR) of children during unstructured play on an inclusive community playground.

Methods

Typically developing children at least 4 years of age were recruited to play freely upon entering the playground. Participants wore a StepWatch4 Activity Monitor and a Polar V800 Sport Watch. Ambulatory measures included total steps, percentage of recommended steps, total ambulatory time (TAT), bout intensity levels/duration periods. Time spent in HR zones and moderate-to-vigorous physical activity (MVPA) was determined.

Results

95 children (48 males; Avg. age: 7 ± 2 years.) were included in this study. Children played for 31.8 ± 14.7 min., were ambulatory for 25.9 ± 12.0 min., took 1826 ± 824 steps, and accumulated 17 ± 8% of the recommended daily step count. Ambulatory bout intensity was predominantly lower intensity and bout durations varied in length. 99% of the play time was spent at a moderate HR or higher. Significant correlations were found between ambulatory and HR measures (ρ range from 0.23 to 0.99, p < 0.05), and 7-10 yo children spent a significantly higher percentage of TAT at higher intensity ambulation (p < 0.05).

Conclusions

Typically developing children can achieve moderate or higher intensity exercise and HR on an inclusive playground. Both typically developing children and those with disabilities, would benefit from a setting where they can interact and participate in parallel play with their peers.

Disparity in Built Environment and Its Impacts on Youths' Physical Activity Behaviors During COVID-19 Pandemic Restrictions

Objectives

Guided by the social ecological model, this study aimed to examine the relations of built environments (i.e., walking/cycling infrastructure, recreation facilities, neighborhood safety/crime), youth’s transition abilities, and changes of youth’s physical activity (PA) and play behaviors due to COVID-19-based restrictions. Ethnic and socioeconomic status (SES) disparities were also examined on studies variables during the COVID-19 restrictions.

Method

A cross-sectional research design was used to assess an anonymous online survey completed by US parents/guardians. The final sample had 1324 children and adolescents (Mean_age = 9.75; SD = 3.95; 51.3% girls), and 35.5% the families were of upper socioeconomic class (income > $150,000). Parents reported the perceived built environment and neighborhood safety, child’s PA and play behaviors during COVID-19 pandemic shelter-in-place restrictions.

Results

Youths who had access to safe built environment were more active and played more outdoor/indoor (p < .01). It was found playing behavior in yard and neighborhood were significantly increased, but community-based play behavior was significantly reduced during COVID-19 restrictions. The SEM analysis (χ²/df = 236.04/54; CFI = .966) supported indirect and direct effects of neighborhood safety on PA changes during COVID-19 restrictions, and the youth’s ability to respond to COVID-19 restrictions served as a full mediator. Low-SES and Hispanic minority youth reported significantly less safety to walking or playing in their neighborhoods than their middle-/high-SES non-Hispanic peers (p < .001). Regardless of ethnicity, the magnitude of the reduction of MVPA was significantly higher among low-SES groups than that of the high- and middle-SES groups (p < .001).

Conclusions

These findings demonstrate a need to tailor programs and policies to help high-risk groups (e.g., low SES) stay active, healthy, and resilient during and after the COVID-19 pandemic.

Comparison of Outcomes by Reconstructive Strategy in Patients with Prostheses for Proximal Femoral Focal Deficiency

BACKGROUND

The present study compares prosthetic treatment options for proximal femoral focal deficiency in terms of gait analysis, oxygen consumption, and patient-reported outcomes.

METHODS

Twenty-three patients who had been managed with a prosthesis for unilateral proximal femoral focal deficiency underwent gait analysis; this group included 7 patients who had received an equinus prosthesis, 6 who had received a rotationplasty prosthesis, and 10 who had undergone Syme amputation and had received an above-the-knee prosthesis. Cadence parameters, kinematic and kinetic data, and oxygen consumption were measured, and the Gait Deviation Index (GDI) was calculated. Medical records and radiographs were reviewed. The Pediatric Outcomes Data Collection Instrument (PODCI) was completed by the child's parent.

RESULTS

Patients underwent gait analysis at a mean age of 11.6 years (range, 4 to 19 years). Proximal femoral focal deficiency classification was not predictive of the chosen treatment. Patients in the rotationplasty group had undergone more procedures than those in the Syme amputation and equinus groups (mean, 3.3, 1.8, and 0.7 procedures, respectively) (p = 0.001). Oxygen cost did not differ between groups; however, all required greater energy expenditure than normal (170%, 144%, and 159%, in the equinus, rotationplasty, and Syme amputation groups, respectively) (p = 0.427). Likewise, hip power, abductor impulse, and GDI did not differ, but all groups had GDI scores >3 standard deviations below normative values. Patients in the equinus group walked faster (97% of normal for age) than those in the rotationplasty (84%) and Syme amputation groups (83%) (p = 0.018), whereas those in the Syme amputation group had superior knee range of motion (55° from the prosthetic knee) than those in the equinus (20°) and rotationplasty groups (15° generated from the ankle) (p = 0.003). There were no differences in terms of the PODCI subscales for pain, sport/physical function, happiness, or global function. Transfer/basic mobility improved with age (r = 0.516, p = 0.017), but no other associations were found between gait variables and PODCI scores.

CONCLUSIONS

Rotationplasty provided no patient-reported benefit and no functional benefit in terms of gait parameters or oxygen consumption, despite requiring more surgical procedures compared with other prosthetic options. Patients with an equinus prosthesis walked the fastest, whereas treatment with a Syme amputation and prosthetic knee yielded equivalent gait parameters and oxygen consumption as compared with those for patients using an equinus prosthesis. These findings contradict those of previous reports that rotationplasty provides superior function over other proximal femoral focal deficiency prosthetic treatment options.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

This is a narrative review of the functional evaluation of clubfoot treatment with gait analysis

Clinicians worldwide have embraced Ponseti’s nonoperative approach in the treatment of clubfoot, primarily due to ubiquitous reports of successful outcomes. A crucial component in this measured success, has come from researchers assessing long-term physical function following nonoperative treatment. Gait analysis has been instrumental in objectively evaluating lower extremity kinematics and kinetics while plantar pressures demonstrate the load bearing patterns experienced in the foot. As technology improves, our ability to evaluate function can take place both in the laboratory setting, and in the community. For over 20 years, our institution has been studying the gait patterns of children treated for clubfoot. After adopting the nonoperative approach, we established a prospective research program that has allowed us to study functional outcomes in the very young walker, through growth to adolescents, and finally at skeletal maturity. We have seen over 450 children treated for clubfoot in the Movement Science Lab, for over 1,250 gait assessments over the span of this study. Early results in 105 children (154 feet) treated nonoperatively for clubfoot, showed 56% of children had normal sagittal plane ankle kinematics, however an incidence of 48% of Ponseti feet had increased dorsiflexion in stance phase, leading us to wonder if this was the result of the tenotomy. Intermediate follow up at age 5 years, showed that the incidence of increased dorsiflexion was reduced (24%) and ankle power did not appear to be affected (P>0.05 compared to controls). The research highlighted in this paper presents the application of functional evaluation through growth and the long-term effects of nonoperative treatment on gait and function. This is a review of the functional outcome studies from our experience at Scottish Rite for Children.

Functional Outcomes Following Treatment for Clubfoot: Ten-Year Follow-up

BACKGROUND

The purpose of this study was to assess function, at the age of 10 years, of children initially treated nonoperatively for clubfoot with either the Ponseti or French physiotherapy program and to compare outcomes in feet that had undergone only nonoperative treatment with those that required subsequent surgery.

METHODS

Gait analysis, isokinetic ankle strength, parent-reported outcomes, and daily step activity data were collected when patients who had been treated for idiopathic clubfoot reached the age of 10 years. Patients who had undergone only nonoperative treatment were compared with those who subsequently underwent extra-articular surgery or intra-articular surgery (posterior release or posteromedial release). The clubfoot groups were compared with age-matched controls.

RESULTS

Of 263 treated clubfeet in 175 patients, 148 had only been treated nonoperatively, 29 underwent extra-articular surgery, and 86 underwent intra-articular surgery (posterior release in 42 and posteromedial release in 44). Significant abnormalities were found in ankle kinetics and isokinetic ankle strength in the feet treated with intra-articular surgery compared with the nonoperatively treated feet (p < 0.017). Compared with controls (n = 40 feet), all groups showed reduced ankle plantar flexion during gait, resulting in a deficit of 9% to 14% for dynamic range of motion, 13% to 20% for ankle moment, and 13% to 23% for power (p < 0.013). Within the intra-articular group, feet that underwent posteromedial release had decreased plantar flexion strength (15%; p = 0.008), dorsiflexion strength (6%; p = 0.048), and parent-reported global function scores (p = 0.032) compared with the posterior release group. The patients with clubfoot took 10% fewer steps (p = 0.015) and had 11% less total ambulatory time (p = 0.001) than the controls.

CONCLUSIONS

Examination of patients when they had reached the age of 10 years showed better ankle power and isokinetic strength for clubfeet treated without surgery compared with those that underwent intra-articular surgery for residual deformity or recurrence. Compared with controls, both nonoperatively and surgically treated clubfeet had significant limitations in ankle plantar flexion resulting in decreased range of motion, moment, and power. Gastrocnemius-soleus complex strength was decreased after both nonoperative and surgical treatment of clubfeet. Although activity was diminished in the clubfoot population, no differences in function were perceived by the patients' parents.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

How Is Pulmonary Function and Exercise Tolerance Affected in Patients With AIS Who Have Undergone Spinal Fusion?

STUDY DESIGN

Prospectively enrolled AIS patients who underwent spinal fusion, with 2 year follow-up.

OBJECTIVES

To evaluate the cardiovascular fitness and activity level in patients with AIS pre- and post-spinal fusion and to determine if initial curve magnitude or pulmonary function is predictive of exercise capacity.

SUMMARY OF BACKGROUND DATA

Researchers have tried to link pulmonary function testing (PFT) to exercise capacity; the results are mixed. Some report no improvement in PFTs or aerobic activity after surgical correction, and PFT measures were not predictive of exercise capacity. Conflicting results have shown Vo_2max results to fall within normal range in AIS patients while PFTs show minimal impairment.

METHODS

AIS patients underwent PFT and oxygen consumption (VO₂) testing during a submaximal graded exercise test (GXT) pre- and post-spinal fusion. Vo_2max was predicted in those patients who completed the test to 85% of maximal heart rate. Pre- to postoperative changes were assessed and then compared to age-matched control subjects. Correlations between Vo_2max and curve severity, pulmonary function, and activity level were assessed.

RESULTS

Thirty-seven patients participated. Vo_2max was predicted in 23 patients pre- and postoperation. There was a significant reduction in Vo_2max postfusion (39.5 ± 6.5 mL/kg/min vs 42.1 ± 8.1 mL/kg/min, p = .033); however, compared with controls (40.5 ± 6.5 mL/kg/min), all data were within the normal range (p > .05). AIS patients reporting high activity had significantly greater Vo_2max than those reporting low activity both pre and postoperatively, but this difference only met statistical significance preop (p < .05). Curve magnitude and PFT measures were not found to correlate with Vo_2max (p > .05).

CONCLUSIONS

Vo_2max in patients with AIS is within normal range both pre- and postfusion. Pulmonary limitations are accommodated for with a slightly increased breathing rate and a slightly reduced overall workload. Activity level rather than curve severity affects Vo_2max outcomes following fusion in AIS.

Comparison of gait after Syme and transtibial amputation in children: factors that may play a role in function

BACKGROUND

Preservation of maximal limb length during amputation is often recommended to maximize the efficiency and symmetry of gait. The goals of this study were to determine (1) whether there are gait differences between children with a Syme (or Boyd) amputation and those with a transtibial-level amputation, and (2) whether the type of prosthetic foot affects gait and PODCI (Pediatric Outcomes Data Collection Instrument) outcomes.

METHODS

Sixty-four patients (age range, 4.7 to 19.2 years) with unilateral below-the-knee prosthesis use (forty-one in the Syme group and twenty-three in the transtibial group) underwent gait analysis and review of data for the involved limb. The twelve prosthetic foot types were categorized as designed for a high, medium, or low activity level (e.g., Flex foot, dynamic response foot, or SACH). Statistical analyses were conducted.

RESULTS

Kinematic differences of <4° in total prosthetic ankle motion and 8° in external hip rotation were seen between the Syme and transtibial groups. Ankle power was greater in the transtibial group, whereas the Syme group had greater coronal-plane hip power (p < 0.05). Prosthetic ankle motion was significantly greater in the high compared with the medium and low-performance feet. However, the PODCI happiness score was higher in patients with low compared with medium-performance feet (p < 0.05).

CONCLUSIONS

Small differences in prosthetic ankle motion and power were found between children with Syme and transtibial amputations. Ankle motion was greater in patients using high-performance feet (9% of the total cohort) compared with medium-performance (59%) and low-performance (31%) feet. Despite the increased ankle motion achieved with high-performance dynamic feet, this advantage was not reflected in peak power of the prosthetic ankle or the PODCI sports/physical functioning subscale.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of amputation level on energy expenditure during overground walking by children with an amputation

BACKGROUND

The oxygen cost of walking by adults with an amputation has been well described, but few studies have focused on this parameter in children who have had an amputation. Children with a transtibial amputation have been reported to maintain walking speed at a 15% higher oxygen cost than able-bodied children. The purpose of this study was to determine if the level of amputation in children has a differential impact on the self-selected speed of walking and the oxygen cost, and how the performance of these children compares with that of a group of able-bodied children.

METHODS

Seventy-three children who had had an amputation participated in this study. Oxygen consumption was measured with a Cosmed K4b2 oxygen analysis telemetry unit (Rome, Italy) as the participants walked overground for ten minutes at a self-selected speed. One minute of steady-state data were reduced, averaged, and standardized to control values. Children with a unilateral amputation were grouped according to the level of the amputation; there were twenty-nine Syme, thirteen transtibial, fourteen knee disarticulation, five transfemoral, and five hip disarticulation amputations. Seven children had had a bilateral amputation, and they were considered as a separate group. Comparisons were made among the five amputation groups and between all children who had undergone amputation and control subjects. The variables that were analyzed were resting VO(2) rate (mL/kg/min), resting heart rate (beats per minute [bpm]), walking VO(2) rate (mL/kg/min), walking VO(2) cost (mL/kg/m), walking heart rate (bpm), and self-selected walking velocity (m/min).

RESULTS

Unilateral transfemoral and hip disarticulation amputations resulted in significantly reduced walking speed (80% and 72% of normal, respectively) and increased VO(2) cost (151% and 161% of normal, respectively), while the heart rate was significantly increased in the hip disarticulation group (124% of normal). Compared with the controls, the children with a bilateral amputation walked significantly slower (87% of normal), with an elevated heart rate (119% of normal) but a similar energy cost. Children with a Syme amputation, transtibial amputation, or knee disarticulation walked with essentially the same speed and oxygen cost as did normal children in the same age group.

CONCLUSIONS

Children with an amputation through the knee or distal to the knee were able to maintain a normal walking speed without significantly increasing their energy cost. Only when the amputation is above the knee do children walk significantly slower and with an increased energy cost.

Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique

BACKGROUND

Currently, clubfoot is initially treated with nonoperative methods including the Ponseti cast technique and the French functional physical therapy program. Our goal was to evaluate the function of children treated with these techniques.

METHODS

We reviewed the cases of 182 patients with idiopathic clubfoot (273 feet) who were initially treated nonoperatively. Seventy-seven patients (119 feet) were excluded because they had either received a combination of nonoperative treatments or had undergone surgery prior to testing. Gait analysis was performed when the children were approximately two years of age. Temporal and kinematic data were classified as abnormal if they were more than one standard deviation from normal.

RESULTS

Gait analysis was performed on 105 patients (fifty-six treated with casts and forty-nine treated with physical therapy) with 154 involved feet (seventy-nine treated with casts and seventy-five treated with physical therapy). These patients were an average of two years and three months of age, and their initial Diméglio scores ranged between 10 and 17. No significant differences in cadence parameters were found between the two groups. The rate of normal kinematic ankle motion in the sagittal plane was higher in the group treated with physical therapy (65% of the feet) than it was in the group treated with the Ponseti cast technique (47%) (p = 0.0317). More children treated with physical therapy walked with knee hyperextension (37% of the feet) (p < 0.0001), an equinus gait (15%) (p = 0.0051), and footdrop (19%) (p = 0.0072); only one patient treated with casts walked with an equinus gait, and only three demonstrated footdrop. In contrast, more of the patients in the cast-treatment group demonstrated excessive stance-phase dorsiflexion (48% of the feet) (p < 0.0001) and a calcaneus gait (10%). More feet in the physical therapy group had an increased internal foot progression angle (44% compared with 24% in the cast-treatment group; p = 0.0144) and increased shank-based foot rotation (73% compared with 57% in the cast-treatment group; p = 0.05).

CONCLUSIONS

While the rate of normal kinematic ankle motion in the sagittal plane was 65% in the group treated with physical therapy, the gait abnormalities that were seen in that group were characterized by mild equinus and/or footdrop. The rate of normal kinematic ankle motion in the sagittal plane was 47% in the cast-treatment group, but the most common gait abnormality in this group was mildly increased dorsiflexion in the stance phase. The rates of calcaneus gait and equinus gait were <or=15% in each nonoperative group. The differences between the physical therapy and cast-treatment groups may, in part, be the result of the percutaneous Achilles tendon lengthening that is performed as part of the Ponseti cast technique but not as part of the physical therapy program.