Walking speed influences spatiotemporal but not symmetry measures of gait in children and adolescents with hemiplegia.

2022

233-236

10/2022

1879-2219

BACKGROUND: The measurement of gait is likely influenced by walking speed in children with hemiplegia, but this relationship is not well characterized.

RESEARCH QUESTION: What is the influence of walking speed on spatiotemporal and symmetry measures of gait in children with hemiplegia, with consideration of side and footwear condition?

METHODS: Children with hemiparetic gait due to stroke were recruited for a small pilot intervention study. Participants walked at self-selected and fast speeds while barefoot and while wearing shoes. Data from baseline sessions were included in this analysis. The influence of walking speed on five spatiotemporal gait measures was determined using a generalized estimating equation to calculate the proportion of variability in the gait measures that was explained by walking speed. Differences between sides and footwear conditions, and the relationships between walking speed and two symmetry measures, are also reported.

RESULTS: A total of 820 steps were analyzed from ten children (11.2 ± 4.1 years). Walking velocity significantly influenced all spatiotemporal measures of gait. As speed increased, step length increased and all temporal measures decreased, on both paretic and nonparetic sides. Wearing shoes increased step length and stance time for both paretic and nonparetic sides, and slowed step time on the nonparetic side. Regardless of footwear, the paretic side demonstrated slower step and swing times, and faster stance and single support times. We did not observe significant relationships between walking speed and gait symmetry.

SIGNIFICANCE: Our observations suggest that walking speed alone influences the spatiotemporal measurement of gait in children with hemiplegia and should be considered in the interpretation of walking function. Yet, controlling for walking speed is often not feasible or not preferred in this population. We offer suggestions for clinicians and researchers who seek to measure gait during overground walking at freely-selected speeds.

10.1016/j.gaitpost.2022.09.088

Gait Posture

36191582

Normalizing step-to-step variability to age in children and adolescents with hemiplegia.

2022

6-8

08/2022

1879-2219

BACKGROUND: Children with hemiplegia often demonstrate gait deviations including increased variability and asymmetry. Step-to-step gait variability decreases over childhood and increases in the presence of neurologic dysfunction. Gait variability in children with hemiplegia should therefore be interpreted in reference to age-related norms RESEARCH QUESTION: Does conversion of the enhanced gait variability index (eGVI) to age-normalized z-scores improve interpretation of gait variability in children with hemiplegia?

METHODS: Ten children (11.2 +/- 4.1 years) with hemiparetic gait due to stroke were recruited for a small prospective pilot intervention study. Participants walked at self-selected speed over an instrumented walkway while barefeet and while wearing shoes. eGVI values from baseline sessions were calculated and converted to age-normalized z-scores (eGVI) based on published norms. Differences in gait variability between sides and footwear conditions, and its relationship to walking speed, were examined.

RESULTS: There were no differences in raw eGVI or eGVI between paretic and nonparetic sides (eGVI p = 0.31; eGVI p = 0.31) or between footwear conditions (eGVI p = 0.62; eGVI p = 0.33). Average raw eGVI values were just over two standards deviations above the reference mean of 100 (121.2, 122.1, 120.3 for mean (average of both limbs), nonparetic side and paretic side, respectively), indicating significantly greater step-to-step gait variability than in typical gait. However, when converted to age-normalized z-scores (eGVI), variability deviated less from the normative sample, averaging just over one standard deviation above the reference mean (1.2, 1.3, 1.1 for mean, nonparetic side and paretic side, respectively). We also observed a relationship between eGVI and walking speed in our sample.

SIGNIFICANCE: We suggest that eGVI values in children be converted to z-scores or otherwise age-normalized so as not to inflate the degree of variability reported in clinical pediatric populations. Future work with larger samples will offer greater insight into gait variability in various clinical pediatric populations.

10.1016/j.gaitpost.2022.08.009

Gait Posture

35994953

5-Year Activity and Participation Outcomes of the First Successful Pediatric Bilateral Hand Transplantation: A Case Report.

2022

1-16

2022 Apr 04

1541-3144

<p><strong>AIMS: </strong>Describe the 5-year outcomes of the first successful pediatric bilateral hand transplantation.</p>

<p><strong>METHODS: </strong>The child underwent quadrimembral amputation at age two and received bilateral hand allografts at age eight. Rehabilitation included biomechanical, neurorehabilitation, and occupational approaches in acute and outpatient settings. Therapist observed outcomes, patient-reported measures, and parent-reported measures were repeated over a 5-year period.</p>

<p><strong>RESULTS: </strong>Observation assessments revealed functional dexterity skills and modified independence to full independence with self-care activities. The parent reported the child had moderate difficulty with upper extremity functioning 25-, 41-, and 48-months post-transplantation, and mild difficulty at 60-months; the child reported no difficulties in this domain at 41 months. Five years post-transplantation the child reported enjoying many age-appropriate activities, and high-quality peer relations were endorsed by both parent and child.</p>

<p><strong>CONCLUSION: </strong>The child developed hand movements for daily activities and was completing daily activities with improved efficiency. Health-related quality of life outcomes were favorable.</p>

10.1080/01942638.2022.2057210

Phys Occup Ther Pediatr

35379065

Periodic and rhythmic patterns in critically ill children: Incidence, interrater agreement, and seizures.

2021

2955-2967

2021 12

1528-1167

<p><strong>OBJECTIVES: </strong>We aimed to determine the incidence of periodic and rhythmic patterns (PRP), assess the interrater agreement between electroencephalographers scoring PRP using standardized terminology, and analyze associations between PRP and electrographic seizures (ES) in critically ill children.</p>

<p><strong>METHODS: </strong>This was a prospective observational study of consecutive critically ill children undergoing continuous electroencephalographic monitoring (CEEG). PRP were identified by one electroencephalographer, and then two pediatric electroencephalographers independently scored the first 1-h epoch that contained PRP using standardized terminology. We determined the incidence of PRPs, evaluated interrater agreement between electroencephalographers scoring PRP, and evaluated associations between PRP and ES.</p>

<p><strong>RESULTS: </strong>One thousand three hundred ninety-nine patients underwent CEEG. ES occurred in 345 (25%) subjects. PRP, ES&nbsp;+&nbsp;PRP, and ictal-interictal continuum (IIC) patterns occurred in 142 (10%), 81 (6%), and 93 (7%) subjects, respectively. The most common PRP were generalized periodic discharges (GPD; 43, 30%), lateralized periodic discharges (LPD; 34, 24%), generalized rhythmic delta activity (GRDA; 34, 24%), bilateral independent periodic discharges (BIPD; 14, 10%), and lateralized rhythmic delta activity (LRDA; 11, 8%). ES risk varied by PRP type (p&nbsp;&lt;&nbsp;.01). ES occurrence was associated with GPD (odds ratio [OR] = 6.35, p&nbsp;&lt;&nbsp;.01), LPD (OR = 10.45, p&nbsp;&lt;&nbsp;.01), BIPD (OR = 6.77, p&nbsp;&lt;&nbsp;.01), and LRDA (OR = 6.58, p&nbsp;&lt;&nbsp;.01). Some modifying features increased the risk of ES for each of those PRP. GRDA was not significantly associated with ES (OR = 1.34, p&nbsp;=&nbsp;.44). Each of the IIC patterns was associated with ES (OR = 6.83-8.81, p&nbsp;&lt;&nbsp;.01). ES and PRP occurred within 6&nbsp;h (before or after) in 45 (56%) subjects.</p>

<p><strong>SIGNIFICANCE: </strong>PRP occurred in 10% of critically ill children who underwent CEEG. The most common patterns were GPD, LPD, GRDA, BIPD, and LRDA. The GPD, LPD, BIPD, LRDA, and IIC patterns were associated with ES. GRDA was not associated with ES.</p>

10.1111/epi.17068

Epilepsia

34642942

Pediatric Hand Transplantation: A Decision Analysis.

2019

1558944719890041

2019 Dec 17

1558-9455

<p>The first successful bilateral pediatric hand transplant was performed in 2015. Previous hand transplant decision analysis models have focused on the adult population. This model principally aimed to determine whether adverse outcomes associated with immunosuppression outweigh the benefits of performing bilateral hand transplant surgery in a pediatric candidate. The model also conceptualized the valuation of losing years of life and sought to determine the impact of that valuation on the surgical decision. A decision model compared undergoing bilateral hand transplant surgery with using prosthetics for an 8-year-old patient. The outcome measure used was quality adjusted life years (QALYs), and sensitivity analysis was performed on the immunosuppressive risks associated with the surgical decision, as well as the perceived valuation of aversion to life years lost. The decision to perform surgery was marginally optimal compared to the prosthetic decision (50.11 QALY vs. 47.95 QALY). A Monte Carlo simulation revealed that this difference may be too marginal to detect an optimal decision (50.14 ± 8.28 QALY vs. 47.95 ± 2.12 QALY). Sensitivity analysis identified decision thresholds related to immunosuppression risks ( = 29% vs. = 33% modeled), and a trend of increasing risk as a patient is more averse to losing life years. The marginally optimal treatment strategy currently is bilateral hand transplant, compared to prosthetics for pediatric patients. Key determinants of the future optimal strategy will be whether immunosuppressive regimens become safer, with a reduced risk of losing life years due to immunosuppressive complications, and whether prosthetics become more acceptable and enable higher functioning.</p>

10.1177/1558944719890041

Hand (N Y)

31847578

18-month outcomes of heterologous bilateral hand transplantation in a child: a case report.

2017

35-44

2017 Sep

2352-4650

<p><strong>BACKGROUND: </strong>Although heterologous vascular composite allotransplantation has become a burgeoning treatment option for adult amputees, there have been no successful cases previously reported in children. Here, we describe the surgical, immunological, and neurorehabilitation details with functional outcomes 18 months after heterologous bilateral hand and forearm transplantation in an 8-year-old child with quadrimembral amputations and a previous kidney transplant.</p>

<p><strong>METHODS: </strong>2 years of extensive preparation by medical and surgical teams preceded the hand-forearm transplantation of this child. The initial immunosuppressive protocol included thymoglobulin, tacrolimus, prednisone, and mycophenolate mofetil. In July, 2015, our vascularised composite allotransplantation team did the first bilateral hand and forearm transplantation in a child, an 8-year-old boy with previous living-related kidney transplantation. The surgery included four teams working simultaneously on the donor and recipient limbs, aided by customised cutting guides that aimed to reduce ischaemia time. Following an extended length of time in hospital, skin biopsies and close monitoring of renal function and drug concentrations occurred weekly for the first 3 months and were slowly tapered to monthly, and then quarterly. Skin biopsies were also done when tissue rejection was suspected. Paediatric-specific rehabilitation techniques were applied to promote patient engagement during rehabilitation. Progress was assessed by monthly sensory and motor function tests during routine clinic visits and with serial functional brain imaging studies, including structural brain MRI, magnetoencephalography and transcranial magnetic stimulation.</p>

<p><strong>FINDINGS: </strong>The surgery lasted 10 h and 40 min. Vascular revision of the ulnar artery was required a few hours postoperatively. There were no further immediate postsurgical complications. Rejection episodes occurred throughout the first year but were reversed. An increase in serum creatinine led to the addition of sirolimus at 3 months after transplantation with concomitant reduction in tacrolimus targets. Sensibility to light touch was present by 6 months after transplantation. Intrinsic hand muscle innervation was present by 7-10 months after transplantation. At 18 months, the child had exceeded his previous adapted abilities. As of 18 months after transplantation surgery he is able to write and feed, toilet, and dress himself more independently and efficiently than he could do before transplantation. He remains on four immunosuppressive medications and functional neuroimaging studies have shown motor and somatosensory cortical reorganisation.</p>

<p><strong>INTERPRETATION: </strong>Hand transplantation in a child can be surgically, medically, and functionally successful under carefully considered circumstances. Long-term data on the functional trajectory, neurological recovery, psychological sequelae, and the potential late effect of immunosuppression are still needed to support broader implementation of paediatric vascular composite allotransplantation.</p>

<p><strong>FUNDING: </strong>The Children's Hospital of Philadelphia.</p>

10.1016/S2352-4642(17)30012-3

Lancet Child Adolesc Health

30169225

Massive cortical reorganization is reversible following bilateral transplants of the hands: evidence from the first successful bilateral pediatric hand transplant patient.

2018

92-97

2018 Jan

2328-9503

<p>In this repeated measures case study, we show that sensory deafferentation after limb amputation leads to changes in cortical somatotopic maps which are reversible after restoration of sensory input. Using magnetoencephalography (MEG), we observed in a child with bilateral hand transplants large-scale shifts in somatosensory lip cortical representation from anatomic hand area to anatomic face region. After recovery of tactile sensation in the digits, responses to finger stimulation were localized to orthotopic sensory cortex, but with atypical electrophysiologic features (amplitude and frequencies).</p>

10.1002/acn3.501

Ann Clin Transl Neurol

29376095

Early antiretroviral therapy is protective against epilepsy in children with human immunodeficiency virus infection in botswana.

2015

193-9

06/2015

1944-7884

<p><strong>BACKGROUND: </strong>Seizures are common among patients with HIV/AIDS in the developing world and are associated with significant morbidity and mortality. Early treatment with combination antiretroviral therapy (cART) may reduce this risk by decreasing rates of central nervous system infections and HIV encephalopathy.</p>

<p><strong>METHODS: </strong>A case-control study of new-onset epilepsy among children aged 0-18 years with perinatally acquired HIV/AIDS followed in Gaborone, Botswana, during the period 2003-2009 was conducted. Children with epilepsy were identified and compared with age- and sex-matched controls without epilepsy with respect to timing of cART initiation. Early treatment was defined as treatment with cART before the age of 12 months, at a CD4% of greater than 25 in children aged 1-5 years, or at an absolute CD4 count of &gt;350 cell per cubic millimeter in children aged 5 years and older.</p>

<p><strong>RESULTS: </strong>We identified 29 cases of new-onset epilepsy and 58 age- and sex-matched controls. The most common identified etiologies for epilepsy were central nervous system infections and direct HIV neurotoxicity. Only 8 (28%) of the children who developed epilepsy received early treatment compared with 31 (53%) controls (odds ratio: 0.36, 95% confidence interval: 0.14 to 0.92, P = 0.03). This effect was primarily driven by differences in rates of epilepsy among children who initiated treatment with cART between the ages of 1 and 5 years (11% vs. 53%, odds ratio: 0.11, 95% confidence interval: 0.01 to 1.1, P = 0.06).</p>

<p><strong>CONCLUSIONS: </strong>Earlier initiation of cART may be protective against epilepsy in children with HIV.</p>

10.1097/QAI.0000000000000563

J. Acquir. Immune Defic. Syndr.

25647527