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To find factors affecting hip and femoral deformities in children with spastic cerebral palsy (CP) by comparing various clinical findings with imaging studies including plain radiography and computed tomography (CT) imaging.
Medical records of 709 children with spastic CP who underwent thorough baseline physical examination and functional assessment between 2 to 6 years old were retrospectively reviewed. Fifty-seven children (31 boys and 26 girls) who had both plain radiography of the hip and three-dimensional CT of the lower extremities at least 5 years after baseline examination were included in this study.
The mean age at physical examination was 3.6 years (SD=1.6; range, 2–5.2 years) and the duration of follow-up imaging after baseline examination was 68.4 months (SD=22.0; range, 60–124 months). The migration percentage correlated with motor impairment and the severity of hip adductor spasticity (R1 angle of hip abduction with knee flexion). The femoral neck and shaft angle correlated with the ambulation ability and severity of hip adductor spasticity (R1 and R2 angles of hip abduction with both knee flexion and extension).
Hip subluxation and coxa valga deformity correlated with both dynamic spasticity and shortening of hip adductor muscles. However, we found no correlation between femoral deformities such as femoral anteversion, coxa valga, and hip subluxation.
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To investigate the effects of repetitive peripheral magnetic stimulation (rPMS) on the vastus lateralis (VL) in the early stage after hip replacement surgery.
Twenty-two patients who underwent hip replacement after proximal femur fracture were included in this study. After hip surgery, the experimental group was applied with 15 sessions of 10 Hz rPMS over the VL 5 times per week for 3 weeks, while the control group took sham stimulation. All patients were also given conventional physical therapy. The VL strength was measured with the root mean square (RMS) value of the VL with surface electromyography technique. The ratio of RMS values between fractured and unfractured legs and tandem stand test were used to assess standing balance. Usual gait speed was measured to evaluate gait function. Pain in two groups was assessed with visual analog scale (VAS).
Both RMS value of the VL and the ratio of RMS values after rPMS were significantly improved (p<0.05). Also, tandem standing time and usual gait speed in rPMS group were dramatically increased (p<0.05). However, no significant difference in VAS was found between the two groups after 3 weeks.
rPMS on the VL improved muscle strength, standing balance and gait function in the early stage after hip surgery. Therefore, rPMS could be applied to patients who cannot take electrical stimulation due to pain and an unhealed wound.
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To identify the prevalence of malnutrition in elderly hip fracture and to investigate the relationship between hip fracture patients and malnutrition on functional recovery and mortality.
All hip fracture patients age >65 years admitted to a rehabilitation unit were recruited from July 2015 to June 2016. Nutritional status was assessed by Mini-Nutritional Assessment Short-Form (MNA-SF) within 72 hours of admission. Patients were reassessed at 6 months for functional status and place of residence. Length of hospital stay, in-patient mortality rate, and 6-month mortality rate were also recorded.
There were 218 patients recruited. The mean age was 83.5±7.5 years. According the MNA-SF, 46 (21.1%) were well nourished, 115 (52.6%) were at risk of malnutrition, and 57 (26.1%) were malnourished. Malnourished individuals were significantly older, had lower Mini-Mental State Examination score and albumin level, were functionally more dependent and were more likely to reside in elderly care facility. A higher proportion of elderly care residents were at-risk or were malnourished on admission, discharge and at 6 months. Functional recovery was slower in the malnourished group. In-patient mortality was higher in malnourished individuals compared to those at risk of malnourishment and well-nourished individuals.
The prevalence of malnutrition is high and is associated with poor functional recovery and elderly care placement. Residents of elderly care facilities are especially at risk due a higher prevalence of malnourishment. Health authorities are encouraged to evaluate the dietetic component in elderly care facilities and initiate nutrition supplementation in their planning of healthcare resources.
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To determine whether there was a difference in balance, proprioception, and skeletal muscle mass among patients who undergo hip fracture surgery relative to and elective total hip replacement (THR).
Thirty-one THR patients were enrolled. The patients were categorized into two groups: fracture group (n=15) and non-fracture group (n=16). Berg Balance Scale (BBS) was used to balance the proprioception of the hip joint while a joint position sense (JPS) test was used to evaluate it. Skeletal muscle mass was measured by bioelectrical impedance analysis and expressed as a skeletal muscle mass index (SMI). Quality of life (QOL) was also assessed using a 36-item short form health survey (SF-36). All tests were assessed at 3 months after the surgery. An independent t-test was used to compare the fracture group and non-fracture group. Spearman correlation was used to identify the correlation of each variable.
In an independent t-test, the BBS score of patients undergoing elective surgery was higher than the BBS score of patients undergoing hip fracture surgery. There was a significant correlation between the BBS and JPS score after a THR. SMI also correlated with the score of BBS.
It seems that THR patients undergoing surgery for a hip fracture might have more trouble balancing than elective THR patients. Therefore THR patients undergoing hip fracture surgery might need more care during rehabilitation.
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To predict ambulatory capacity, 1 month after physical therapy following hip fracture surgery.
A retrospective chart review was carried out. Patients more than 60 years old, who underwent hip fracture surgery and received physical therapies, were selected (n=548). Age, gender, presence of cognitive dysfunction, combined medical diseases, combined fractures, previous history of hip surgery, prefracture ambulatory capacity, days from the fracture to surgery, type of fracture, type of surgery, presence of postoperative complications, days from the surgery to physical therapy, and total admission period, were collected. Prefracture ambulatory capacity and postoperative ambulatory capacity were classified into non-ambulatory status (NA), ambulation with assistive device (AA), and independent-ambulation without any assistive device (IA). Multiple-logistic regression analysis was performed for the prediction of postoperative ambulatory capacity.
Age (odds ratio [OR]=0.94 for IA and 0.96 for IA or AA), gender (OR=1.64 for IA and 0.98 for IA or AA), prefracture ambulatory capacity (OR of IA=19.17 for IA; OR of IA=16.72 for IA or AA; OR of AA=1.26 for IA, OR of AA=9.46 for IA or AA), and combined medical disease (OR=2.02) were found to be the factors related to postoperative ambulatory capacity and the prediction model was set up using these four factors.
Using this model, we can predict the ambulatory capacity following hip fracture surgery. Further prospective studies should be constructed to improve postoperative ambulatory capacity.
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To investigate the effects of hippotherapy on psychosocial and emotional parameters in children with cerebral palsy (CP) and their caregivers.
Eight children with CP were recruited (three males and five females; mean age, 7.3 years; Gross Motor Function Classification System levels 1–3). Hippotherapy sessions were conducted for 30 minutes once weekly for 10 consecutive weeks in an indoor riding arena. The Gross Motor Function Measure (GMFM), Pediatric Balance Scale (PBS), and the Korean version of the Modified Barthel Index were evaluated. All children were evaluated by the Children's Depression Inventory, Trait Anxiety Inventory for Children, State Anxiety Inventory for Children, Rosenberg Self Esteem Scale, and the Korean-Satisfaction with Life Scale (K-SWLS). Their caregivers were evaluated with the Beck Depression Inventory, the Beck Anxiety Inventory, and the K-SWLS. We assessed children and their caregivers with the same parameters immediately after hippotherapy.
Significant improvements on the GMFM, dimension E in the GMFM, and the PBS were observed after hippotherapy compared with the baseline assessment (p<0.05). However, no improvements were detected in the psychosocial or emotional parameters in children with CP or their caregivers. None of the participants showed any adverse effects or accidents during the 10 weeks hippotherapy program.
Hippotherapy was safe and effectively improved gross motor and balance domains in children with CP. However, no improvements were observed in psychosocial or emotional parameters.
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Hip and pelvic pain during pregnancy or after delivery is a common problem in young females, and in most cases this problem has a self-limiting course. The patient described in this case suffered from severe hip pain after childbirth. MR imaging study was performed and it showed arthritis of bilateral hip joints and osteomyelitis of femoral heads with an abscess in the surrounding muscle. Infection, such as septic arthritis or osteomyelitis, is an extremely rare cause of peripartum joint pain. The patient's clinical symptoms and laboratory findings improved with antibiotic therapy. However, limitation of motion of the bilateral hip joints persisted although the patient continued rehabilitative therapy for 15 months, and the patient had to undergo bilateral total hip replacement. Hereby, we present a case of severe osteomyelitis and pyogenic arthritis of bilateral femoral heads and hip joints after delivery, which eventually required bilateral total hip replacement.
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To investigate the prognostic factors predicting the recovery of pre-fracture functional mobility, we evaluated this by the use of ambulatory assistive devices in short-term follow-up.
Five hundred and fifty-three elderly patients who had undergone hip fracture operations from January 2006 to June 2013 were enrolled in this retrospective study. Clinical characteristics and predicted factors affecting functional recovery, such as the delay of rehabilitation after the operation, were reviewed. The functional status of the gait was classified as either a bedridden state, wheelchair-bound state, walker gait, single cane gait, and self-gait without any ambulatory assistance device. When this functional grade in patients who recovered after the surgery was compared to before the surgery, this state was considered 'functional recovery'.
One hundred and ninety-two patients (34.7%) showed recovery of preoperative mobility in the first month after their operation. Multiple logistic regression analysis identified that the following four factors were significantly associated with a deterioration of functional recovery: old age (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.92-0.97), delays in rehabilitation after operation (OR, 0.94; 95% CI, 0.89-0.98), the presence of cognitive dysfunction (OR, 0.36; 95% CI, 0.18-0.71), and trochanteric fracturing (OR, 0.58; 95% CI, 0.36-0.94).
We found that old age, cognitive dysfunction, trochanteric fracture type, and delay of rehabilitation were associated with the deterioration of functional recovery after a hip fracture operation in the short-term. Therefore, early rehabilitation was required to acquire functional recovery after a hip fracture operation in the short-term.
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To determine whether a routine ultrasonography (US) is necessary for diagnosis of developmental dysplasia of hip (DDH), presenting with congenital muscular torticollis (CMT).
Cases of 133 patients (81 males, 52 females) diagnosed as CMT were reviewed, retrospectively. We reviewed the medical charts and diagnostic examination. We also assessed the coincidence of CMT and DDH, and investigated the clinical features of CMT related to DDH.
Twenty (15.0%) patients out of 133 CMT patients were diagnosed as having DDH by US. Of whom, 8 patients were radiographically positive and 4 patients were both clinically and radiographically positive. Nine patients were treated with a harness and 1 of them needed closed reduction and casting. Out of 9 patients treated with a harness, only 4 were clinically positive. The difference and ratio of the sternocleidomastoid (SCM) muscle thickness between the normal and abnormal side was significantly greater in DDH patients (p=0.014). Further, receiver operating characteristic analysis showed when the SCM ratio is greater than 2.08 and the SCM difference is greater than 6.1 mm, the efficiency of US for the diagnosis of the DDH was found to be the best (p<0.05).
To evaluate DDH, physical examination showed low sensitivity and radiologic study has limitation for the child before 4 to 6 months of age. Therefore, we recommend that hip is screened by US for the diagnosis of DDH associated with CMT when physical examination is positive or CMT patients with large SCM difference and high SCM ratio.
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To investigate the therapeutic effects of mechanical horseback riding for gait and balance parameters in post-stroke patients.
This study was a non randomized prospective positive-controlled trial over a 12 week period. From May 2011 to October 2011, 37 stroke patients were recruited from our outpatient clinic and divided into two groups. The control group received the conventional physiotherapy while the intervention group received the conventional physiotherapy along with mechanical horseback riding therapy for 12 weeks. Outcome measurements of gait included the Functional Ambulation Category (FAC) and gait part of the Performance Oriented Mobility Assessment (G-POMA) while those of balance included the Berg Balance Scale (BBS) and the balance part of the Performance Oriented Mobility Assessment (B-POMA). These measurements were taken before and after treatment.
There were no significant differences in the baseline characteristics and initial values between the two groups. When comparing baseline and 12 weeks post treatment in each group, the intervention group showed significant improvement on BBS (39.9±5.7 → 45.7±4.8, p=0.001) and B-POMA (10.4±2.6 → 12.6±2.1, p=0.001), but significant improvement on gait parameters. When comparing the groups, the dynamic balance category of BBS in post treatment showed significant difference (p=0.02).
This study suggests that mechanical horseback riding therapy may be an effective treatment tool for enhancing balance in adults with stroke.
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To investigate the effects of hippotherapy for adult patients with brain disorders.
Eight chronic brain disorder patients (7 males, mean age 42.4±16.6 years) were recruited. The mean duration from injury was 7.9±7.7 years. The diagnoses were stroke (n=5), traumatic brain disorder (n=2), and cerebral palsy (n=1). Hippotherapy sessions were conducted twice a week for eight consecutive weeks in an indoor riding arena. Each hippotherapy session lasted 30 minutes. All participants were evaluated by the Berg balance scale, Tinetti Performance-Oriented Mobility Assessment, 10 Meter Walking Test, Functional Ambulatory Category, Korean Beck Depression Inventory, and Hamilton Depression Rating Scale. We performed baseline assessments twice just before starting hippotherapy. We also assessed the participants immediately after hippotherapy and at eight weeks after hippotherapy.
All participants showed no difference in balance, gait function, and emotion between the two baseline assessments before hippotherapy. During the eight-week hippotherapy program, all participants showed neither adverse effects nor any accidents; all had good compliance. After hippotherapy, there were significant improvements in balance and gait speed in comparison with the baseline assessment (p<0.05), and these effects were sustained for two months after hippotherapy. However, there was no significant difference in emotion after hippotherapy.
We could observe hippotherapy to be a safe and effective alternative therapy for adult patients with brain disorders in improving balance and gait function. Further future studies are warranted to delineate the benefits of hippotherapy on chronic stroke patients.
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To determine reliability and clinical use of two methods of migration index (MI) in CP patients with or without hip dysplasia.
The materials included radiographs of 200 hips of children with cerebral palsy. Conventional anteroposterior radiographs of the pelvis were taken with the child in the supine position with standardized methods. Two rehabilitation doctors measured the migration index using two methods. In the classic method, the lateral margin of the acetabular roof was used as a landmark and in the modified method the lateral margin of the sourcil was used as a landmark. Each rater measured the migration index at three separate times with a time interval of at least one week. Intraclass correlation (ICC) was used to test the inter- and intra-rater reliability.
MI shows excellent intra-rater reliability in both the classic and modified methods, but the inter-rater reliability was higher in the classic method than in the modified method. When categorized according to the sourcil classification, inter-rater reliability was higher in the normal sourcil type and lower in the dysplastic sourcil types.
Generally, the classic method showed higher reliability than the modified method, even though the reliability of the MI measurement was relatively high with both methods.
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To evaluate the validity of physical examinations by assessment of correlation between physical examinations and CT measurements in children with intoeing gait and the causes of intoeing gait by age using CT measurements.
Twenty-six children with intoeing gait participated in this study. The internal and external hip rotation, thigh-foot angle and transmalleolar angle were measured. In addition, femoral anteversion and tibial torsion of the subjects were assessed using a CT scan. The measurements of torsional angles were performed twice by two raters. The correlation coefficients between physical examinations and CT measurements were calculated using Pearson correlation. The data was analyzed statistically using SPSS v12.0.
The correlation coefficients between physical examinations and CT measurements were not high. Before 5 years of age, intoeing gait was caused by femoral anteversion in 17.86%, tibial torsion in 32.29% and the combination of causes in 35.71% of cases. After 6 years of age, the contributions changed to 29.17%, 8.33% and 45.83%, respectively.
Before 5 years of age, the common cause of an intoeing gait was tibial torsion, whereas after 6 years of age it was femoral anteversion. Regardless of age, the most common cause of intoeing gait was a combination of causes. This study shows poor correlation between physical examinations and CT. Therefore, it is limiting to use physical examination only for evaluating the cause of intoeing gait in clinical practice.
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To investigate the coexistence rate and related factors of developmental dysplasia of the hip (DDH) and congenital muscular torticollis (CMT), and to determine whether ultrasonography (US) gives good value for screening of DDH in CMT.
We prospectively examined 121 infants (73 males and 48 females) diagnosed with CMT to determine the incidence of DDH by US. We also assessed the relationship between neck US findings and DDH occurrence, and investigated the clinical features of CMT related to DDH.
18 patients (14.9%) were diagnosed as having DDH by US. However, most DDH was subclinical and spontaneously resolved. Only 2 patients (1.7%) needed to be treated with a harness. The positive predictive value of clinical examinations for DDH was 52.6% and patients treated by harness were all clinically positive. DDH was more common in the left side (13 left, 4 right, 1 both), but 6 out of 18 DDH (33.3%) cases presented on the contralateral side of CMT. Sex difference was not observed. Breech presentation and oligohydramnios were not related to DDH occurrence. Neck US findings did not correlate with DDH occurrence.
The coexistence rate of CMT and DDH was concluded to be 14.9%. If only DDH cases that required treatment were included, the coexistence rate of these two disorders would be lowered to 1.7%. All of these patients showed positive findings in clinical examination. Therefore, hip US should not be recommended routinely for patients with CMT.
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Transient osteoporosis of the hip (TOH) is a rare disorder of unknown etiology that is characterized by acute onset of disabling bone pain. The locally increased bone turnover and low bone mineral density (BMD) associated with this disorder indicate a potential role for an antiresorptive agent such as bisphosphonate as a treatment. A previously healthy 46-year-old man developed the sudden onset of pain in his right buttock and inguinal area, especially during walking and caused him to limp. A thorough medical workup including X-ray, MRI, and bone SPECT revealed transient osteoporosis of the hip, and he was treated with an infusion of zoledronate (5 mg). Two weeks later, he was fully recovered from pain and the gait disturbance. A follow-up MRI of the hip joint taken after 6 months showed complete resolution. The use of intravenous zoledronate provided a successful outcome in the treatment of TOH. The possibility of TOH should be considered in patients complaining of sudden hip pain and a limping gait. MR imaging played an important role for differentiation of TOH from other aggressive conditions with long term sequelae.
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Objective: Hip deformity is one of the common problems in children with cerebral palsy. And it is important to detect hip subluxation or dislocation as early as possible. The purpose of this study is to find the incidence of hip subluxation in early childhood in patients with cerebral palsy.
Method: We reviewed clinical and radiological records of children with cerebral palsy under 36 months of age. We measured migration index, acetabular index, center edge angle and neck shaft angle from hip X-ray of patients.
Results: Total 76 patients were included in this study. The mean of migration index was 4.5⁑7.5% at 8∼12 months, 10.9⁑11.9% at 13∼24 months, and 18.2⁑13.0% at 25∼36 months (p＜0.05). Twenty one patients (27.6%) were above 25% on the migration index. The neuromotor type of cerebral palsy in 21 patients with hip subluxation, were spastic in 20 (95.2%) except one child. The incidence of hip subluxation was 25.0% (8/32) for quadriplegia, 29.6% (8/27) for diplegia and 50.0% (4/8) for hemiplegia. The acetabular index was significantly higher and the center edge angle was lower in the subluxated hip group than in the non-subluxated hip group, though no significant difference in the neck shaft angle.
Conclusion: We concluded that the hip subluxation in cerebral palsy can occur under 36 months of age with a relatively high incidence. Therefore, it is recommended to evaluate the hip of cerebral palsy with radiological as well as clinical examination in early childhood. (J Korean Acad Rehab Med 2002; 26: 514-518)
Objective: The purpose of this study is to evaluate objectively and quantitatively gait improvement after total hip arthroplasty (THA) using a 3-dimensional computerized Vicon motion analyzer.
Method: A preoperative gait evaluation was performed within one month before surgery and two postoperative gait evaluations at 6 months intervals after surgery. Pre- and postoperative gait parameters of 176 patients with unilateral total hip arthroplasty were evaluated and data were compared with those of 56 healthy persons.
Results: 1) Single limb support of affected limb increased significantly at postoperative 6 and 12 months compared with preoperative data. 2) The improvements of hip flexion and abduction of affected limb were in almost normal range at postoperative 12 months. 3) Maximal hip flexor moment in terminal stance of affected limb reached to nearly normal level at postoperative 12 months.
Conclusion: A quantitative gait analyzer is a very useful tool to assess objectively the success of THA as substantiated by the results of this study with a significant improvement in all the parameters of gait., Unilateral total hip arthroplasty, Gait analysis, Kinematics of hip joint
Objective: To determine the functional outcomes of the patients with total hip replacement and to evaluate the variables associated with the functional recovery.
Method: Subjects were 188 patients, who had undertaken total hip replacement between March 1, 1997 and July 31, 1999 at Asan Medial Center. The four functional milestones including sitting, standing, 50 m walking, and climbing stairs were evaluated.
Results: The average duration of treatment was 8.3⁑7.0 days, and the days required for sitting were 1.9⁑1.0; standing 2.4⁑1.8; walking 50 m 6.4⁑4.3; climbing stairs 7.9⁑4.5 days. In results of analysis of each variable, male patients showed faster functional improvement than female patients in standing and climbing stairs. The patients of age 60 years and over had slower recovery in sitting and standing. The patients with sequelae of septic hip or Legg-Calve-Perthes disease had slower recovery than the others in standing. The patient with the use of cement showed rapid improvement in sitting and standing. Those who could bear full weight had rapid recovery than those with partial weight.
Conclusion: We would like to suggest that careful consideration on characteristics of each patient should be given in determining the duration of rehabilitation management of the patients who had total hip replacement.
Objective: The purposes of this study were (1) to determine the effectiveness of intensive rehabilitation on ambulatory recovery in patients after hip fracture with previous cerebrovascular accident; (2) to define the difference in the ambulatory outcome of the hip fracture patients according to their previous history of stroke.
Method: One hundred and seventy-three cases with hip fracture were studied. All patients were divided into two groups: Group A with and Group B without a history of stroke prior to the fracture. The following information was obtained in each patients: age, sex, type and side of fracture, side of hemiplegia, duration of hospitalization, concurrent disease. Ambulatory status was divided as satisfactory (walking with quad-cane or walking frame or mono-cane) or nonsatisfactory (confined to wheelchair or to a bed) accordong to their recovery after rehabilitation.
Results: Twenty three percent of patients have the history of stroke with hip fracture on hemiplegic side and 51.4% of them regained their prefracture level of ambulation. No significant difference was found in the incidence of concurrent disease, length of hospital stay, and functional recovery between hip fracture patients with and without a history of stroke.
Conclusion: We conclude that rehabilitation of the stroke patient with hip fracture is worthwhile and comprehensive rehabilitation should be done in hip fracture patients with or without hemiplegia.
There have been a many reports of observational analysis on hip disarticulation prosthetic ambulation, but not a scientific analysis by a computerized motion analyzer. We present to share with our professional colleague our invaluable experience gained from the study on the gait analysis of a left hip disarticulation prosthetic gait.
Using a Vicon 370 three dimensional gait analysis system, the gait analysis was performed in a left hip disarticulation patient fitted with a left Canadian type hip disarticulation prosthesis.
In linear parameters, the cadence showed 79 steps/min, the gait speed was 0.68 m/sec, and the double support phase was 25.27% of a total gait cycle. In kinematics, the maximal pelvic tilt angle showed 29.92o at pre-swing phase, and significantly increased as compared with normal person. Hip motion change remained flexed, and maximal knee flexion angle disclosed 22.07o at the terminal stage of initial swing phase. In kinetics, the hip extension moment on initial contact stage was 0.089 NM/kg, which was impaired being compared with normal person.
In conclusion, the increased pelvic tilt which implies that initiation of a prosthetic gait for hip disarticulation comes from a forward swing of the pelvis on the affected side, and an overall decrease of gait parameters accounts for the degree of disability of hip disarticulation amputee.
The obturator nerve is originated in lumbar 2, 3, 4 roots and inserted at the inner muscle of thigh, by way of sacral ala and obturator foramen. In the case of pelvic surgery or obstetric trauma, the obturator neuropathy is occasionally occurred. However, the obturator neuropathy is rarely seen in the orthopedic accident.
In literature, one case of obturator neuropathy is reported after 2,012 cases of total hip replacement surgery. The useful diagnostic tools of obturator neuropathy are needle EMG on the obturater nerve innervated muscle, not conduction test on the nerve.
We report of a case of obturator neuropathy after closed reduction of posterior hip dislocation complicated by traffic accident with a brief reviewed of literatures.
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