Electromyographic differentiation of diplegic cerebral palsy from idiopathic toe walking: involuntary coactivation of the quadriceps and gastrocnemius.

Clinical differentiation of patients with mild diplegic cerebral palsy (CP) and idiopathic toe walking (ITW) can be difficult. However, an involuntary extensor pattern may be a distinguishing sign. The purpose of this study was to determine if selected gait parameters or patterns of electromyogram (EMG) timing of quadriceps, gastrocnemius, and tibialis anterior during knee extension while sitting can distinguish between these patients. The hypothesis was that EMG testing for selective control of the quadriceps and gastrocnemius could differentiate patients with diplegic CP from normal controls and from patients with ITW. We evaluated 10 control, eight CP, and eight ITW subjects. Measurements included walking speed, energy expenditure index (EEI), ankle position during stance, and EMG of the quadriceps, gastrocnemius, and tibialis anterior during gait and during knee extension while sitting. Dynamic EMG timing during gait showed significant differences in the mean onset of the gastrocnemius between subjects with CP and ITW, but there was considerable overlap. More consistent differences were found during active and active-resisted knee extension while sitting. Mean values for gastrocnemius EMG timing recorded as a percentage of duration of quadriceps EMG while sitting were 0 and 0.4% for controls, 0 and 3.9% for ITW subjects, and 84.3% and 93.4% for CP subjects. Patterns of EMG timing of the quadriceps and gastrocnemius during knee extension while sitting can help to differentiate patients with mild diplegic CP from those with ITW.

Analysis of radiographic measurements as prognostic indicators of treatment success in patients with developmental dysplasia of the hip.

Measurements were taken and statistically analyzed from the initial radiographs, the 1-year follow-up radiographs, and the most recent radiographs of 81 patients (103 hips) to determine which measurements could predict the success of treatment. The average follow-up was 49 months (range, 12-139 months), and the average age of the patients at the last follow-up was 65 months (range, 15-190 months). Analysis of the data showed that the measurement with statistically significant predictive value was the Tonnis grade of dislocation determined from the initial radiograph. A single unit increase in the Tonnis grade was associated with a doubling of the odds of failure in patients treated with a Pavlik harness (P < 0.04, odds ratio = 2.2) or a closed reduction (odds ratio = 2.0).

Postural balance measurements for children and adolescents.

Measurements of standing balance were determined for 92 children and adolescents, 5-18 years old, while they stood on a force plate with eyes open or eyes closed. The measurements included center-of-pressure calculations for path length per second, average radial displacement, anterior-posterior and mediolateral amplitudes, area per second, mean frequency of sway, Brownian random motion measure of short-term diffusion coefficient, and long-term scaling exponent. All balance parameters improved from youngest to oldest subjects, and the parameters improved when measured with the subjects' eyes open compared with closed. The mean values for data from three trials varied by only 5% when compared with the mean values from 10 trials. Data from this study suggest that force-plate center-of-pressure data can be used to determine differences in standing balance between children and adolescents of different ages and those with movement and balance abnormalities.

Effectiveness of ice packs in reducing skin temperature under casts.

Skin temperature lowering effects were measured after application of crushed ice packs to the surface of synthetic and plaster casts. The skin temperature of legs in synthetic casts decreased an average of 10.4 degrees C (range, 8.3 degrees-12.6 degrees) to a minimum temperature of 19.7 degrees C (range, 16.2 degrees-21.8 degrees), and the temperature of legs in plaster casts decreased an average of 11 degrees C to a minimum of 18.7 degrees C (range, 13 degrees-22.8 degrees). It took an average of 56 minutes (range, 40-80 minutes) for the legs in synthetic casts and 63.8 minutes (range, 26-116 minutes) for the legs in plaster casts to reach the minimum temperature. Cryotherapy is used clinically with the intention of lowering skin temperature and presumably decreasing the pain and swelling of a patient's injured extremity. The presence of a synthetic or a plaster cast does not eliminate the lowering effects of skin temperature when crushed ice packs are applied to the surface of the casts.

Loss of elbow and wrist motion in hemophilia.

The longitudinal changes in elbow and wrist motion for 48 patients with hemophilia were reviewed to determine the effect of recurrent hemarthroses. The average age of the patients at the time of followup was 23 years 9 months. The average duration of followup was 10.8 years. The patients were divided into 3 age groups: younger than age 15 years (14 patients), age 15 to 25 years (11 patients), and older than age 25 years (23 patients). For patients older than age 25 years, pronation, supination, elbow flexion and extension, wrist flexion and extension, and ulnar deviation were significantly decreased relative to patients younger than age 15 years. Pronation was the first motion to show a significant change, decreasing by 19% in patients age 15 to 25 years and by 31% in patients older than age 25 years. Loss of elbow extension showed the greatest change. In cases of severe hemophilic arthropathy of the elbow, synovectomy and radial head excision decreased elbow pain and bleeding episodes and improved supination and pronation.

Gastrointestinal problems in patients who have type-III osteogenesis imperfecta.

We performed a study of forty-three patients who had type-III osteogenesis imperfecta. Our purpose was to determine the frequency and severity of abdominal problems and the relationship between these problems and pelvic deformity. Twelve patients had had recurrent episodes of abdominal pain. Eleven of them had a history of chronic constipation, and five had been treated for fecal impaction. Radiographs had been made for ten of these patients, and eight of them had radiographic evidence of pelvic deformity with severe acetabular protrusion. Chronic constipation and recurrent abdominal pain are more frequent in patients who have osteogenesis imperfecta and acetabular protrusion than in those who do not have protrusion. These patients may benefit from early attention to a bowel program and referral to a gastrointestinal specialist.

Muscle pathology and clinical measures of disability in children with cerebral palsy.

We performed a histologic and morphometric study of spastic muscle from 10 children with diplegic cerebral palsy, comparing muscle structure with the gait parameters of energy expenditure index and dynamic electromyography. Variations in fiber area within and between fiber types were increased significantly in children with cerebral palsy. In each of the control subjects, the combined coefficient of variation for type-1 and type-2 fiber area was less than 25% and the average was 17%; in the subjects with cerebral palsy, the combined coefficient of variation was more than 25% and the average was 36% (p < or = 0.004). The average difference between the mean area of type-1 and type-2 fibers was 26.7 +/- 18.9% for subjects with cerebral palsy and 4.2 +/- 2.4% for control subjects (p < or = 0.004). There was a 67% predominance of one fiber type in the subjects with cerebral palsy compared with a 55% predominance in the control subjects (p < or = 0.03). The difference between the total area of type-1 and type-2 fibers was 57% in the subjects with cerebral palsy and 17% in the control subjects (p < or = 0.002). There was a significant correlation between the combined coefficient of variation of fiber area and the energy expenditure index (r = 0.77, p < or = 0.03). The difference between the mean area of type-1 and type-2 fibers correlated with prolongation of electromyographic activity (r = 0.69, p < or = 0.05). No abnormalities in fiber ultrastructure were found in the subjects with cerebral palsy. Children with cerebral palsy had abnormal variation in the size of muscle fibers and altered distribution of fiber types. The values for variation in fiber area correlated with the energy expenditure index and with prolongation of electromyographic activity during walking.

A comparison of oxygen pulse and respiratory exchange ratio in cerebral palsied and nondisabled children.

Energy expended while walking is increased for children with cerebral palsy compared to nondisabled children. This study compared oxygen uptake, oxygen pulse, and the respiratory exchange ratio (RER) in children with cerebral palsy and nondisabled children walking on a treadmill. Resting oxygen uptake and oxygen pulse values were not different in the two groups. At a given walking speed, oxygen uptake, oxygen pulse, and RER were higher for subjects with cerebral palsy. At a given level of submaximal oxygen uptake, oxygen pulse and RER values were not different in subjects with cerebral palsy compared to nondisabled children. It was concluded that the cardiorespiratory response to walking at submaximal level of work is not significantly different for children with cerebral palsy.

Transverse cervicopertrochanteric hip fracture.

A 3-year-old boy sustained a previously undescribed transverse hip fracture that involved the cervical, cervicotrochanteric, and intertrochanteric regions. The fracture was successfully treated with skeletal traction for 4 weeks using a Steinmann pin placed through the distal femoral metaphysis followed by spica cast immobilization. The 3-year follow-up examination demonstrated satisfactory growth and remodeling of the proximal femur with no evidence of osteonecrosis, premature physeal closure, or coxa vara.

The energy expenditure index: a method to quantitate and compare walking energy expenditure for children and adolescents.

We used heart rate and walking speed to calculate an energy expenditure index (EEI), the ratio of heart rate per meter walked, for 102 normal subjects, age 6-18 years. Heart rate was measured at self-selected slow, comfortable, and fast walking speeds on the floor and on a motor-driven treadmill. At slow walking speeds (37 +/- 10 m/min) the EEI was elevated (0.71 +/- 0.32 beats/m), indicating poor economy. At comfortable speeds (70 +/- 11 m/min) the EEI values decreased to the maximum economy (0.47 +/- 0.13 beats/m). At fast speeds (101 +/- 13 m/min), the EEI increased (0.61 +/- 0.17 beats/m), indicating poor economy relative to comfortable speeds. A graph of the EEI versus walking speed provides a way to evaluate and compare energy expenditure in a clinical setting.