Health-related quality of life and ambulation in children with myelomeningocele in a Swedish population.

AIM: The aim was to study health-related quality of life (HRQL) in Swedish children with myelomeningocele (MMC) with respect to ambulatory function. METHODS: A physical examination of the lower limbs was performed, and occurrence of orthopaedic deformities and shunted hydrocephalus was documented. A questionnaire on general health-related quality of life Child Health Questionnaire-50 Parent Form (CHQ-PF50) was answered by the parents of 62 children, mean age 12.5 (3.1) years. RESULTS: The non-ambulatory children had significantly more frequent spasticity in the lower limbs, more often joint contractures as well as hip dislocation or spine deformity compared with ambulating patients. Thirty-two per cent of the ambulators managed without wheelchair use. All non-ambulators were wheelchair users, of which 60% used both a manual and a powered wheelchair. The children with MMC perceived significantly lower HRQL of all subscales of CHQ compared with the healthy control group. Physical function was significantly higher in ambulatory patients, PF = 57.1 compared with 22.2 for non-ambulatory patients. CONCLUSION: A Swedish population of children with MMC perceived lower HRQL compared with healthy children, but similar HRQL irrespective of ambulatory function except for the physical domain was reported.

Workplace aesthetics: impact of environments upon employee health as compared to ergonomics.

Associations between self-reported needs for aesthetic and ergonomic improvements were studied to analyse a possible impact of aesthetic needs on job performance as compared to ergonomic needs in 11 occupational groups. Employees at Swedish broadcasting company were invited to participate in a cross sectional study. 74% (n=1961/2641) fulfilled the inclusion criteria. Demographic data from company files and a pre-validated questionnaire were used. 'High rank' and 'low rank' aesthetic and ergonomic needs were compared. The perceived needs for aesthetic and ergonomic improvements showed significantly different distributions (p<0.001). Aesthetic needs were more frequently reported. No gender related differences were observed. Differences between occupational groups were shown (p=0.006, 0.003).'High rank' needs for aesthetic and ergonomic improvements were similarly associated to psychological demands, stress, pain and age. 16/24 factors showed significant differences between 'high and low rank' aesthetic needs, whereas 21/24 between ergonomic needs. Sick leave was stronger related to ergonomics. The study results show a relation between not only work place ergonomics but also work place aesthetics to health and well-being. Future work health promotion and prevention may benefit from the inclusion of workplace aesthetics.

Kinematic and kinetic analysis of static sitting of patients with neuropathic spine deformity.

Wheelchair dependent children with neuropathic and neuromuscular diseases have up to 90% risk for progressive spine deformities. An unbalanced sitting can induce progression of spinal and pelvic deformities. Many current clinical assessment methods of sitting of such patients are semi-quantitative, or questionnaire-based. A 3D movement analysis offers quantitative and objective biomechanical analysis of sitting. The aim was to validate a method to describe quiet sitting and differences between patients and controls as well as to apply the methodology for pre- and post-operative comparison. The analysis was performed on 14 patients and 10 controls. Four patients were retested after spine surgery. Seat load asymmetry was up to 30% in the patient group comparing to maximum 7% in the control group. The asymmetric position of Ground Reaction Force vector between left and right sides was significant. Plumb line of cervical 7th vertebra over sacral 1st was different only in rotation. The location of Common Center of Pressure relative to inter-trochanteric midpoint was more anterior in controls than in patients. Pelvic inclination in patients was smaller, the obliquity and rotation was similar. There were no significant differences between patients and controls of the thorax position. Results with more changes in the seat-loading domain in comparison with posture indicate good postural control compensation of spinal deformity induced disequilibrium despite neuromuscular disease in the background. The comparison of the pelvic obliquity data from kinematics and X-ray showed good correlation. The four patients tested postoperatively improved after surgery.

Workplace aesthetics: Impact of environments upon employee health?

Associations between self-reported need for aesthetic improvements in the workplace and the need for ergonomic improvement and health factors were investigated to determine the possible impact of aesthetic needs on job performance. The need for aesthetic improvements were compared with the need for ergonomic improvements. All employees at a Swedish broadcasting company were invited to participate in this cross sectional study. Of those who fulfilled the inclusion criteria the participation rate was 74% (1961/2641). Demographic data was obtained from company files and pre-validated questionnaire was used for data collections from the participants. additional questions on needs for improvement were developed, tested for repeatability, and demonstrated to be within acceptable limits. Differences between 'high rank' and 'low rank' aesthetic needs and ergonomic needs were correlated to set ups of demographic, work environmental and organisational and health variables.The perceived needs for aesthetic and ergonomic improvements showed significantly different distributions (p<0.001). Aesthetic needs were more frequently reported than ergonomic needs. There was no significant gender related difference in response distribution of aesthetic or ergonomic needs, whereas differences between occupational groups were shown (0.006 and 0.003). 'High rank' needs for aesthetic improvement were associated to psychologically demanding work, negative work stress, sleep disturbances, problems at work, musculoskeletal pain and lower age. Gender and physical training did not differ between 'high and low rank' responders regarding neither aesthetic nor ergonomic needs. Sick leave was stronger related to ergonomics. The independently tested associations with aesthetic needs were similar to, but fewer than those for ergonomic needs with regard to the variable set ups. Sixteen studied factors out of 24, showed significant difference between 'high and low rank' aesthetic needs, and 21/24 of ergonomic needs, independently tested. The study results show a relation between work place aesthetics and health and well-being. Future work health promotion and prevention may benefit from the inclusion of an assessment of workplace aesthetics.

One-stage major spine deformity correction surgery: comparison between groups with and without additional neurosurgical intervention, with more than 24 months of follow-up. Clinical article.

OBJECT: Early-onset, nonidiopathic spine deformities are frequently caused by intraspinal anomalies necessitating both neurosurgical and orthopedic intervention. The clinical tradition at most treatment units is to perform neurosurgical and orthopedic procedures separately. Sometimes the deformity correction surgery is also done in stages, which leads to several periods of hospitalization, increased use of health care resources, and a long rehabilitation time for the patient. The purpose of this project was to perform an outcome survey for major spine surgery in high-risk patients, and to analyze whether an additional neurosurgical intervention during the same session increased the risk of complications. METHODS: A consecutive series of 81 patients with major rigid spine deformities treated by the same orthopedic surgeon was analyzed. In 24 of 81 cases there were additional intraspinal pathological entities indicating a neurosurgical procedure. All cases were divided into 2 groups: one with anterior-posterior surgery and also neurosurgery, and the other with anterior-posterior surgery but without neurosurgery. The result variables for the group comparisons were as follows: clinical and radiographic outcome, operating time, length of intensive care and hospital stay, relative blood loss, and occurrence of complications or adverse events. Groups were similar in terms of sex, size of spinal curve, and surgical procedures, but different in terms of diagnosis (there were more patients with myelomeningocele in the group treated with both anterior-posterior surgery and neurosurgery) and patient age (the group with both anterior-posterior surgery and neurosurgery was younger). RESULTS: An additional neurosurgical procedure combined with fusion surgery did not increase the complication rate or use of resources compared with fusion surgery alone, except in the length of operating time. The mean correction of the spinal curve was 56.7%, and the mean correction of the pelvic obliquity was 74.7%. The loss of correction was 3° on average. A more than 10° progression was seen in 9 cases. There were no deaths, and there were no neurological complications or surgery-related deterioration of ambulatory function. There were 10 complications that altered the planned postoperative course, including 5 infections. CONCLUSIONS: One-stage major spine surgery, even when neurosurgery is included, is safe and does not increase the risk of complications. The increase in hospital and ICU stays is marginal.

Outcome of major spinal deformity surgery in high-risk patients: comparison between two departments.

STUDY DESIGN: Retrospective cohort studyObjective: To describe the outcome and resource use in major spine surgery on high-risk patients, and analyze possible differences between two surgical departments. METHODS: Data from the deformity register and medical records of 136 patients, median age 12-years, with neuromuscular and congenital spinal deformities with and without intraspinal pathology, surgically treated by one surgeon from 1997 through 2004 at two departments. H1 with a pediatric multidisciplinary team, and H2 with focus on adult spine. Variables at baseline: age, gender, diagnosis, curve size, and type of surgical procedure. Result variables included clinical and radiographic outcome, surgery time, length of intensive care and hospital stay, relative blood loss, and occurrence of complications during 2 or more years follow-up. RESULTS: There was no perioperative or postoperative mortality, no spinal-cord damage, no neurological or ambulatory function deterioration. The overall complication rate was 36%, and the overall major complication rate was 15.4%. The mean loss of correction was 2° during the follow-up. There were statistically significant differences between the H1 and H2 departments. At H1, deformity correction was better and surgery time shorter. Infections were more frequent at H2 (P = .04; 6/65 at H1; 16/71 at H2), tendency (P = .06) of more department-related complications was higher at H2. CONCLUSIONS: Major spine surgery in high-risk patients can be performed safely and with good outcoms. Impact of organization and workplace culture on the outcome might be important and worth further study.

Impact of a web-based stress management and health promotion program on neck-shoulder-back pain in knowledge workers? 12 month prospective controlled follow-up.

OBJECTIVE: To evaluate the influence of a web-based stress management program on neck-shoulder-back pain and perceived pain-relatedness to stress in a prospective and controlled study. METHODS: Study points were baseline, after 6 months intervention and at 12 months follow-up on 226 news media employees in two study groups and one control group. RESULTS: Between groups no significant differences were found at any study point. Within groups, the study group with less intensive program improved in pain-relatedness to stress at follow-up. Between baseline and after intervention, the group with more intensive program showed decreased low back pain, and the control group showed less pain-relatedness to stress. Within group differences varied according to pain localization and were inconsistent. CONCLUSION: Present web-based stress management program did not influence neck-shoulder-back pain or perceived pain-relatedness to stress in stress-intensive occupations.

Seat load characteristics in children with neuromuscular and syndrome-related scoliosis: effects of pathology and treatment.

The amount of correction from spine deformity surgery that is required to avoid asymmetric and unbalanced sitting is not known, and methods sensitive enough to document moderate changes in pressure distribution over time are few, as the commonly used methods are qualitative or semiquantitative. The aim was to analyse seating pressure distribution with a pressure sensor mat system in patients with nonidiopathic scoliosis and to compare the pressure distribution with that in able-bodied controls. The aim was also to apply the method in a surgically treated scoliosis group before and after the spine fusion. Peak pressure, contact area of the entire and the maximum pressure surface, and three measures of asymmetry were calculated. Patients had higher peak pressure and more asymmetric loading than controls. Significant difference was indicated in contact area. After the spine fusion, all asymmetry indices improved. The method fulfilled clinical needs to detect the differences from normal controls as well as the surgery-dependent changes.

Shoulder pain in persons with thoracic spinal cord injury: prevalence and characteristics.

OBJECTIVE: To document the prevalence of shoulder pain, associated patient characteristics, and intensity and interference with shoulder function in activities in wheelchair users. DESIGN: A cross-sectional survey. PATIENTS: Individuals with a thoracic spinal cord injury. METHODS: A 3-part questionnaire on patient characteristics, medical history, supplemental questions, and the Wheelchair Users Shoulder Pain Index was administered to 101 patients. RESULTS: Of the 88 subjects (87%) who completed the questionnaire, 40% reported experiencing current shoulder pain, often chronic in nature. The highest median intensity of shoulder pain was reported for pushing the wheelchair up ramps or inclines outdoors. Reports of limitations regarding the ability to use the shoulder in activities were common. Most subjects used no upper extremity assistive devices during transfer or wheelchair propulsion. Of those with current shoulder pain, 37% had not sought medical attention. Age was associated with ongoing shoulder pain. CONCLUSION: Shoulder pain is a common problem in wheelchair users with a thoracic spinal cord injury, it seems more likely to occur with increased age, and is a potential cause of activity limitations. The findings indicate a need to develop programmes of prevention, patient education, diagnosis and treatment, possibly including more frequent use of upper extremity assistive devices.

Stress biomarkers' associations to pain in the neck, shoulder and back in healthy media workers: 12-month prospective follow-up.

Physiological and psychological mechanisms have been proposed to link stress and musculoskeletal pain (MSP), and a number of stress biomarkers in patients with chronic pain have shown to be associated with stress-related disorders as well as health and recovery. The aim was to study if similar results might be found in a working population, in stress and computer intensive occupations with mild/moderate pain in neck, shoulder and back. The questions were if there are: (1) associations between self rated neck, shoulder and back pain (VAS) on one hand and stress-related (catabolic), recovery related (anabolic) variables, cardiovascular/lifestyle factors and immune markers on the other hand. (2) associations between long term changes in pain and stress marker values (6 month period). (3) predictive values in stress biomarkers for pain (12 month period) A study group with 121 media workers, 67 males (average 45 years) and 53 females (average 43 years), at three news departments of a media company was recruited. Pain occurrence and pain level in neck, shoulder, upper and low back were self-rated at three times with a 6-month interval towards the last month. Stress biomarker sampling was performed, at the same intervals. An additional similar questionnaire with momentary ratings focusing on "at present" i.e. within the same hour as stress biomarker sampling was performed. There were no changes in medicine intake or computer working hours during the 12 month study period. The total pain level and prevalence of pain decreased between baseline and 12 months follow-up. The rate of participation was 95%. Cross-sectional analyses on differences in stress biomarkers in groups of "no pain" and "pain" showed less beneficial stress biomarker levels (P < 0.05) in the "pain" group after age and gender adjustments in: S-DHEA-S and P-endothelin, S-insulin and P-fibrinogen. Analyses of each gender separately, adjusted for age, revealed in males differences in S-insulin, saliva cortisol 3, and P-endothelin. Furthermore, tendencies were seen in BMI, P-fibrinogen, and S-testosterone. In the female "pain" group a less beneficial P-BNP level was found. Longitudinal analysis of changes in pain levels and stress biomarkers within an interval of 6 months showed beneficial changes in the following stress markers: P-NPY, S-albumin, S-growth hormone and S-HDL when pain decreased, and vice versa when pain increased. Linear regression analyses showed statistically significant predicting values at the initial test instance for pain 12 months later in lower S-DHEA-S and S-albumin and higher B-HbA1c and P-fibrinogen. In stepwise regression and after age and gender adjustments, the associations with S-DHEA-S remained statistically significant. The present study shows that individuals in working life with a high level of regenerative/anabolic activity have less pain than other subjects, and that decreased regenerative/anabolic activity is associated with increasing pain. The levels of NPY, albumin, GH and HDL increased when pain decreased and vice versa. Low DHEA-S predicted pain 12 months later. These findings might contribute to increased knowledge about strategies to prevent further progression of neck/shoulder/back pain in persons who are "not yet in chronic pain".

Associations between orthopaedic findings, ambulation and health-related quality of life in children with myelomeningocele.

PURPOSE: Modern principles for treatment of patients with myelomeningocele include early closure of the neural tube defect, neurosurgical treatment of hydrocephalus and treatment aimed at minimizing contractures and joint dislocations. The aim is to achieve a better survival rate and a better quality of life (QOL). Better ambulatory function is thought to improve the management of activities of daily living. This study focused on evaluating which factors might affect ambulation, function and health-related QOL in children with myelomeningocele. METHODS: Thirty-eight patients with neurological deficit from myelomeningocele were examined in an unbiased follow-up. This included a physical examination using validated methods for ambulatory function and neuromuscular status, chart reviews and evaluation of radiographs in terms of hip dislocation and spine deformity. The Pediatric Evaluation of Disability Inventory (PEDI) was used to measure mobility, self-care and social function, and the Child Health Questionnaire (CHQ-PF50) was used to measure QOL. RESULTS: Muscle function class, quadriceps strength, spasticity in hip and/or knee joint muscles and hip flexion contracture as well as the ambulatory level all affected functional mobility as well as self-care/PEDI. Patients with hip dislocation, spinal deformity or those who were mentally retarded also had significantly worse functional mobility. Besides being affected by the severity of the neurological lesion, self-care/PEDI was significantly impaired by hip flexion contracture and absence of functional ambulation. General health-related QOL was significantly lower in this patient group than for US norms. Nonambulatory and mentally retarded patients had a significantly lower physical function of their QOL (CHQ). CONCLUSIONS: The severity of the disease, i.e. reduced muscle strength and occurrence of spasticity around hip/knee, affected ambulation, functional mobility and self-care. Acquired deformities (hip dislocation and spine deformity) affected functional ambulation only. Patients with reduced functional mobility and self-care experienced lower physical QOL. Children with myelomeningocele had significantly reduced QOL compared to healthy individuals.

Comparison and evaluation of two common methods to measure center of mass displacement in three dimensions during gait.

Center of mass displacement during gait has frequently been used as an indicator of gait efficiency or as a complement to standard gait analysis. With technological advances, measuring the center of mass as the centroid of a multi-segment system is practical and feasible, but must first be compared to the well-established Newtonian computation of double-integrating the ground reaction force. This study aims to verify that the kinematic centroid obtained from a commonly-used model (Vicon Peak Plug-In-Gait) provides at least as reliable measurements of center of mass displacement as those obtained from the ground reaction forces. Gait data was collected for able-bodied children and children with myelomeningocele who use larger lateral center of mass excursions during gait. Reasonable agreement between methods was found in fore-aft and vertical directions, where the methods' excursions differed by an average of less than 10 mm in either direction, and the average RMS differences between methods' computed curves were 6 and 13 mm. Particularly good agreement was observed in the lateral direction, where the calculated excursions differed by an average of less than 2 mm and the RMS difference was 5 mm. Error analyses in computing the center of mass displacement from ground reaction forces were performed. A 5% deviation in mass estimation increased the computed vertical excursion twofold, and a 5% deviation in the integration constant of initial velocity increased the computed fore-aft excursions by 10%. The suitability of calculating center of mass displacement using ground reaction forces in a patient population is questioned. The kinematic centroid is susceptible to errors in segment parameters and marker placement, but results in plausible results that are at least within the range of doubt of the better-established ground reaction force integration, and are more useful when interpreting 3-D gait data.

The influence of spasticity in the lower limb muscles on gait pattern in children with sacral to mid-lumbar myelomeningocele: a gait analysis study.

Gait analysis and recording of standing position were performed in 38 ambulatory children with myelomeningocele. Thirty-four were independent ambulators and four required a walking aid. All subjects were assigned one of four muscle function groups based on muscle strength. They were also divided into subgroups based on the distinction between flaccid and spastic paresis in the lower limb joints. A comparison was made between the gait pattern of the children with spasticity and that of the children with flaccid paresis in each muscle function group. Spasticity in only the ankle joint muscles influenced the subject's gait and standing position compared to the subgroups with a flaccid paresis. Even larger deviations in gait and standing position were observed when spasticity occurred in muscles at the knee and hip joints. When setting ambulatory goals the presence of additional neurological symptoms such as spasticity and inadequate balance should be taken into consideration.

Kinetics of compensatory gait in persons with myelomeningocele.

This study investigated the kinetic strategy and compensatory mechanisms during self-ambulatory gait in children with lumbo-sacral myelomeningocele. Thirty-one children with mid-lumbar to low-sacral myelomeningocele who walked without aids and 21 control children were evaluated by three-dimensional gait analysis. Joint moments in all planes at the hip and knee and sagittal moments at the ankle, as well as joint power and work done at all three joints, were analyzed. Joint moment capacity lost due to plantarflexor and dorsiflexor weakness was provided instead by orthotic support, but other joints were loaded more to compensate for the weakness at the ankles and restricted ankle motion. Subjects with total plantarflexor and dorsiflexor paresis and strength in the hip abductors had more knee extensor loading due to plantarflexor weakness and dorsiflexion angle of the orthotic ankle joint. The subjects with orthoses also generated more power at the hip to supplement the power generation lost to plantarflexor weakness and fixed ankles. The most determinant muscle whose paresis changes gait kinetics was the hip abductor. Hip abductor weakness resulted in a characteristic pattern where the hips displayed an eccentric adduction moment, mediating energy transfer into the lower limbs, and the hips replaced the knees as power absorbers in early stance. Joint moment, power and work analyses complement a kinematic analysis to provide a complete picture of how children who have muscle paresis recruit stronger muscle groups to compensate for weaker ones.

Measuring seating pressure, area, and asymmetry in persons with spinal cord injury.

The goal of this study was to measure characteristics of seat loading in manual wheelchair users with complete spinal cord injury (SCI). Pressure distribution on the seating area of 25 adult males with SCI and eight non-injured adult males was measured in a relaxed and an upright posture on a standardized hard surface. Subjects with SCI were also tested in their wheelchairs. Maximum pressure, contact area, area of the highest pressure, and three asymmetry indices were compared. Subjects with SCI have higher pressure distributed over a smaller area, have a much smaller contact area, and distribute the loading more asymmetrically than non-injured subjects. Upright posture only corrects for some loading problems, while the wheelchair corrects for more loading parameters. Routine clinical seat loading evaluation may lead to improved chair and cushion selection for patients with SCI and may even alert clinicians to patients at high risk for complications due to high or unbalanced loads.

Centre of mass motion during gait in persons with myelomeningocele.

The movement of the centre of mass in the vertical and lateral directions during gait in children with myelomeningocele was analyzed. The children were classified into five groups depending on the successive paresis of lower limb muscle groups and compared to a control group. In the groups with dorsi- and plantarflexor weakness, the excursions increased and an anterior trend in the centre of mass was observed. In the groups with additional abductor paresis, the lateral excursion was highest and the vertical excursion low due to increased transverse and frontal motion and reduced sagittal motion. With further paresis of the hip extensors, the centre of mass was more posteriorly positioned due to compensatory trunk extension. Improved understanding of individual children's solutions to their muscle paresis can be obtained by visualizing the centre of mass relative to the pelvis. Centre of mass analyses in myelomeningocele offer an important complement to standard gait analysis.

Characteristic gait kinematics in persons with lumbosacral myelomeningocele.

Thirty self-ambulatory children with mid-lumbar to low-sacral myelomeningocele who walked without aids and 21 control children were evaluated by three-dimensional gait analysis. Characteristic kinematic patterns and parameters in the trunk, pelvis, hip, knee and ankle were analyzed with respect to groups with successive weakness of the ankle plantarflexor, ankle dorsiflexor, hip abductor, hip extensor and knee flexor muscles. Extensive weakness of the plantarflexors resulted in kinematic alterations in the trunk, pelvis, hip and knee and in all three planes seen as knee flexion, anterior pelvic tilt and trunk and pelvic rotation. Additional extensive weakness of the dorsiflexors made little difference in the walking strategy. Large kinematic alterations in all planes were observed where there was a large extent of additional weakness of the hip abductor but strength remaining in the hip extensors. In this group, gait was characterized by large lateral sway of the trunk, rotation of the trunk and pelvis, pelvic hike and increased extension of the knees. In the group with total poresis hip extensors but yet some knee flexion, gait was similar to the previous group but there was less sagittal plane movement greates and posterior trunk tilt. Gait analysis provides an understanding of the compensatory strategies employed in these patients. Clinical management can be directed towards stabilizing the lower extremities and accommodating large upper body motion to preserve this method of self-ambulation even in children who have considerable hip extensor and abductor weakness.

Somatosensory testing in idiopathic scoliosis.

Sixty-seven consecutive patients (59 females, eight males; mean age 13.6 years, age range 8.1 to 18 years) with adolescent idiopathic scoliosis were evaluated for segmental dystonia, thermal and vibratory thresholds, and cortical somatosensory evoked potentials (cSEPs). Clinically, there were no signs of segmental dystonia. No significant side difference was found in cSEPs and thermal thresholds. Vibration thresholds were increased on the right side with a significant side difference at all sites. However, these changes did not correlate to curve size, rotation, curve type, or convexity. It was concluded that, at the present level of somatosensory testing, no segmental neurophysiological disturbance can be related to the appearance of idiopathic scoliosis. The importance of asymmetric vibratory thresholds measurements cannot be deduced from this study.