Background and Purpose The limited walking ability that follows a stroke restricts the patient’s independent mobility about the home and community, a significant social handicap. To improve the in-hospital prediction of functional outcome, the relationships between impairment, disability, and handicap were assessed with clinical measures in 147 stroke patients. Methods The patients’ level of functional walking ability at home and in the community was assigned by expert clinicians to one of the six categories of a modified Hoffer Functional Ambulation scale at least 3 months after discharge. A 19-item questionnaire was further used to assess current customary mobility of the subjects. Functional muscle strength and proprioception were tested, and walking velocity was measured. Results The significant indicators of impairment, upright motor control knee flexion and extension strength, differentiated household from community ambulators. The addition of velocity improved the functional prediction. Propriocept...

Classification of Walking Handicap in the Stroke Population

The energy expenditure of normal and pathologic gait.

We devised a new Functional Mobility Scale (FMS) to describe functional mobility in children with cerebral palsy, as an aid to communication between orthopaedic surgeons and health professionals. The unique feature of the FMS is the freedom to score functional mobility over three distinct distances, chosen to represent mobility in the home, at school and in the wider community. We examined the construct, content, and concurrent validity of the FMS in a cohort of 310 children with cerebral palsy by comparing the FMS to existing scales and to instrumented measures of physical function. We demonstrated the scale to be both valid and reliable in a consecutive population sample of 310 children with cerebral palsy seen in our tertiary referral center. The FMS was useful for discriminating between large groups of children with varying levels of disabilities and functional mobility and sensitive to detect change after operative intervention.

The Functional Mobility Scale (FMS).

The role of intramuscular botulinum toxin A in the treatment of 26 children with cerebral palsy was evaluated. The indication for injection was the presence of a dynamic contracture of lower-limb muscles interfering with positioning or walking. Spastic target muscles were identified by clinical examination and, in ambulant children, by gait analysis. Between 50 and 320 units of botulinum toxin were injected into each muscle group to a total dose of 100 to 400 units per child. The effects of injection were monitored by repeated clinical examination and gait analysis. There were no clinically detectable systemic side-effects, and all but one patient had a reduction in tone, which occurred within three days and persisted for two to four months. There were significant improvements in ambulatory status and in sagittal-plane kinematics. In some cases these gains persisted after the tone-reducing effects of the toxin had worn off.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1469-8749.1994.tb11864.x

Botulinum toxin in the management of the lower limb in cerebral palsy

A 10-level, parent-report walking scale encompassing a range of walking abilities from nonambulatory to ambulatory in all community settings and terrains was developed at Gillette Children's Specialty Healthcare (GCSH) as part of the Gillette Functional Assessment Questionnaire (FAQ). The reliability and validity of the walking-scale portion of the FAQ were tested on a group of individuals seen in the Motion Analysis Laboratory at GCSH between May 1996 and January 1997. A complete data set on 41 individuals with neuromuscular conditions represented the community ambulation levels (6-10) of the walking scale. Good test-retest reliability among parents and good interrater reliability between parents and community caregivers was demonstrated. Content and concurrent validity were also high, as assessed by correlation to standardized functional outcome measures, energy expenditure, and gait-analysis information. A reliable and valid scale specific to the task of walking such as the FAQ can assist clinicians in documenting functional change in children with chronic neuromuscular conditions.

Reliability and validity of the Gillette Functional Assessment Questionnaire as an outcome measure in children with walking disabilities.

The factors important in achieving good walking status in myelomeningocele include level of paraplegia, the additional anomalies of brain and kidney, the intelligence, and the home environment. In a group of fifty-six patients none of those with lesions of the thoracic level walked and all of those with lesions of the sacral level walked. In those with lesions at lumbar levels (twenty-one lower and nineteen upper) fourteen were community ambulators and five household ambulators. The other twenty-one were either wheel-chair (nineteen) or non-functional ambulators (two) and the level of paraplegia did not seem to matter nor did the extent of surgery. Some very young non-functional ambulators rose in functional level, but in most instances the trend was to deteriorate.

Functional ambulation in patients with myelomeningocele.

We reviewed the long-term outcome of thirty-six patients who had a myelomeningocele at the sacral level and whose average age was twenty-nine years (range, nineteen to fifty-one years). The patients were followed at our institution for an average of ten years (range, one to thirty-three years); however, the medical records from birth on were available for all of the patients. Instead of the expected outcome that function had been maintained in this group of patients, we found a decline in the ability to walk of eleven of the thirty-five patients who had been community ambulators initially. At the time of the most recent follow-up examination, five had become household ambulators, two were non-functional ambulators, and four were non-ambulators. The one patient who initially had been a household ambulator was a non-ambulator at the time of the most recent follow-up examination. A decrease in plantar flexion was found in fourteen patients and a decrease in plantar sensation, in fifteen. Breakdown of the skin and soft-tissue infections on the plantar surface of the metatarsal heads and of the heel were seen in twenty-seven and twenty-three patients, respectively, and were related to the absence of plantar sensation. Fifteen patients had osteomyelitis involving the lower extremity. Eleven patients had had a total of fourteen amputations: five involved one toe or more, four involved one ray or more, two were Syme amputations, and three were below-the-knee amputations. By the most recent follow-up examination, thirty-three patients had had a total of 371 orthopaedic procedures. The procedures included tendinous procedures; osteotomies; soft-tissue releases, transfers, and debridements; amputations; and arthrodeses of the lower extremities or spine.

Myelomeningocele at the sacral level. Long-term outcomes in adults.

As initial surgical management for rigid equinovarus deformities, 16 children with arthrogryposis (30 involved feet) and 16 myelodysplastic children (26 involved feet) underwent primary talectomies or extensive posterior-medial releases (PMR). When compared with primary PMRs in arthrogrypotic children, primary talectomies revealed a greater number of good and fair results, decreased recurrence rates, less procedures per foot, and maintenance of ambulatory status. Recurrent forefoot and cavus deformities were present after primary talectomies. Primary talectomy in arthrogrypotic children was more effective than posterior-medial releases or secondary (salvage) talectomy. Because of the small number of feet involved, the role of primary talectomy in myelomeningocele was not clarified by this study. Radical PMRs in myelodysplastic children resulted in a significant number of hindfoot valgus deformities that required secondary procedures.

Equinovarus deformity in arthrogryposis and myelomeningocele: evaluation of primary talectomy.

The oxygen consumption of 15 myelodysplastic children during walking and propelling a wheelchair was studied. In comparison to normal children, they walked more slower and consumed more oxygen per meter, but had a similar rate of oxygen consumption. A swing-through gait pattern was 33 per cent more energy-efficient than a four-point gait pattern for these children. Wheelchair propulsion produced velocities and energy efficiencies similar to normal children walking. Oxygen consumption and velocity measurements were found to be significantly related to the clinical factors of level of lesion and strength of hip and knee extension. Regression lines and equations are presented to permit prediction of energy cost and efficiency from heart-rate data of myelodysplastic children.

Energy cost of walking and of wheelchair propulsion by children with myelodysplasia: comparison with normal children.

To clarify the role the flexor tendon to extensor hood transfer (Girdlestone-Taylor procedure) may have in correction of clawtoes in myelodysplasia, 20 patients with residual paralysis from myelomeningocele who underwent the procedure between 1976 and 1985 were reviewed. They were evaluated for the effectiveness of the procedure and occurrence of late deformities. A total of 25 feet with 65 toes were evaluated in patients ranging in age from 0.6 to 38.8 years. Results were classified as good if toes were straight, fair if mild deformity was present, and poor if definite clawing was noted. The overall results showed 60% good, 34% fair, and 6% poor results. Toes followed less than 24 months had more good results than those with longer follow-up. There was little difference in the results between great toes and lesser toes. No serious complications occurred. Our results indicate a sufficient level of success to utilize this method for correction of flexible claw toe deformities without resorting to bony procedures. We suggest this should be particularly useful in children.

Earl Feiwell

Papers

Functional ambulation in patients with myelomeningocele.

Myelomeningocele at the sacral level. Long-term outcomes in adults.

Equinovarus deformity in arthrogryposis and myelomeningocele: evaluation of primary talectomy.

Energy cost of walking and of wheelchair propulsion by children with myelodysplasia: comparison with normal children.

Review of the Girdlestone-Taylor Procedure for Clawtoes in Myelodysplasia: