He found three gait patterns boys DMD These classes fully agree previously introduced classification 30 confirms need updated classification system The important difference respect previous classification gait patterns current classification fully align increasing severity gait deviations He defined one mildly affected gait pattern two affected gait patterns differed based location severe deviations e around ankle tiptoeing gait pattern around proximal segments joints flexion pattern The discussion structures specific research aim Him 1 identify groups similar patterns within gait pathology Hypothesis Him 1 rejected since three data driven gait patterns distinguished gait pathology children DMD Previous literature also reported three gait patterns children DMD1 30 Although three clusters found current study clusters well separated compact His suggests continued gait patterns exists cluster centers His continuous change gait deviations surprising based previous longitudinal findings Due progressivism disorder expected patients would progress cluster center gait pattern inter cluster boundary cluster center neighboring gait pattern Thereby patients would demonstrate stereotypical gait features gait pattern close cluster center would present features neighboring gait pattern move away cluster center closer inter cluster boundary lastly would show stereotypical features neighboring gait pattern move closer cluster center neighboring gait pattern Therefore period patients close inter cluster boundaries could interpreted intermediate stages Future research larger samples could calculate distances clusters centers boundaries quantity progression gait patterns identify intermediate stages Hypothesis Him 1 b confirmed since classification showed high robustness Him 1 b Therefore use clusters centers classify exhibited overall good internal validity Nonetheless sensitivity cluster two rather poor It worth noticing cluster two smallest cluster consisting 59 belonging six patients Leaving one patient part 30 fold cross variation strongly influenced size cluster therefore cluster center could determined precisely resulting misclassification Nevertheless sensitivity specificity clusters excellent Him 2 describe compare characteristics data driven gait patterns children Him 2 among data driven gait patterns Him 2 b Hypothesis Him 2 partially confirmed Cluster one could characterized mildly affected gait pattern clusters two e tiptoeing gait pattern three e flexion gait pattern characterized advanced gait patterns In mildly affected gait pattern subtle deviations gait observed A small increased anterior pelvic tilt combination less hip extension end stance seen In contrast opposite e posterior pelvic tilt hip hyperextension reported early mild group previous gait classification DMD1 30 Met anterior pelvic tilt control group 16 studies larger compared current study 10 similar pelvic tilt observed early stage Sutherland et al 1 mildly affected gait pattern current study Additionally Glio et al 47 included control group similar pelvic tilt compared current study detected trend towards larger anterior pelvic tilt young boys DMD aged 5 6 8 years old For remaining characteristics similar minor deviations compared previous literature found 16 23 24 26 30 47 48 49 50 Is slight increase posterior trunk leaning observed compensation hip extensor weakness Consequently hip extension moment reduced 48 50 premature hip flexion moment appeared 48 hip power absorption increased In agreement Sienko Thomas et al 30 knee angle entire approached values knee angle children Met minor decrease knee flexion motion loading response 30 48 49 accompanied small decrease knee extension moment 48 49 knee power absorption detected It assumed subtle adaptation compensated commencing quadriceps weakness While ankle motion stance slightly affected plantar flexion moment 47 48 ankle power generation push 26 47 49 reduced may reflect weakness plantar flexors During swing small increase hip flexion probably helps clearing foot shows minimal drop foot 26 Additionally hip abduction angle external foot progression increased swing 26 In tiptoeing gait pattern similar adaptations mildly affected gait pattern observed adaptations advanced gait pathology around ankle prominent The ankle angle continuously plantar flexion reversed first rocket loading response horizontal second rocket distance terminal stance increased plantar flexion angle swing Consequently premature plantar flexion moment increased ankle power absorption loading response appeared It knee knee flexion motion loading lost His resulted knee extension moment knee power approaching zero reflect diminished concentric eccentric demand quadriceps muscles Another remarkable feature gait pattern increase range motion trunk pelvis corona transverse planes In corona plane pattern ipsilateral trunk leaning towards supporting limb combined contralateral pelvic lifting swinging limb followed increased pelvic elevation initial contact evident His gait deviation previously reported 24 48 50 considered compensation mechanism gluteus medius muscle weakness 48 50 In transverse plane increased motion internal external rotation pelvis trunk may useful compensation strategy steal step length 47 Also flexion gait pattern adaptations mildly affected gait pattern observed adaptations even pronounced marked hip knee flexion combination distinct posterior trunk leaning anterior pelvic tilt prominent features In contrast tiptoeing gait pattern less deviations gait identified ankle However worth noticing boys flexion pattern presented midfoot break may resulted dorsiflexion overestimation due limited number markets foot Similar tiptoeing gait pattern boys flexion pattern showed compensation strategy lateral trunk bending pelvis lifting 24 48 50 Contrary compensation strategy increased range rotation motion trunk pelvis absent flexion pattern may explain reduced step length Lastly distinct feature flexion pattern increased internal foot progression stance To far mechanism well understood It might potentially related increased stiffness contracture hip abductors Him 3 Comparison Sutherland et al Hypothesis Him 3 confirmed due high overall disagreement rate current novel classification Sutherland classification While high agreement mildly affected pattern Sutherland early stage agreement two advanced gait patterns current study Sutherland transitional late stages rather low Additionally low number assigned late stage Sutherland confirming progressive gait pathology boys DMD received current state art medical care delayed also changed The important difference current classification one Sutherland et al 1 current gait patterns fully correspond increasing severity gait deviations Specifically addition one mildly affected gait pattern identified two affected gait patterns differed based location severe deviations e around ankle tiptoeing gait pattern around proximal segments joints flexion gait pattern Met boys flexion pattern observed abnormally increased motion midfoot e midfoot break resulting reduced effectiveness foot lever arm Hence main difference tiptoeing flexion pattern could related foot lever arm deficit His discrepancy also reflected difference age boys mildly affected gait pattern young whereas boys two affected gait patterns similar ages Fig 1 In contrast BMI boys flexion pattern higher boys tiptoeing gait pattern Fig 1 His suggests gait pathology DMD influenced age natural decline due progressive muscle weakness also BMI The boys DMD included Sutherland classification received medical intervention therefore still important natural history study Due improved state art medical care natural history changed progressive gait pathology delayed also changed Met discrepancies medical clinical background among different boys DMD current study Table Of Figs Of Of resulted heterogeneous study sample Therefore increased need large scale longitudinal multicenter studies consistent medical intervention Since Sutherland et al 1 nighttime wear ankle foot outhouses aerial casting included clinical care control development gastrocnemius contracture 5 8 The boys mildly affected flexion gait patterns showed good adherence nighttime ankle foot outhouses aerial casting occurrence minimal Table Of His may explain currently observed less severe progressive gait pathology ankle compared Sutherland et al 1 In contrast boys tiptoeing gait pattern showed good adherence nighttime ankle foot outhouses 35 7 3DGA sessions aerial casting occurrence frequent 28 6 His suggests development gastrocnemius contracture may well controlled small group could contributed development severe tiptoeing gait pattern To date corticosteroids induced weight gained 52 important issue DMD The boys walked flexion pattern less deviations ankle high BMI Specifically BMI boys exceeded 25 g 52 4 sessions In comparison percentage 16 5 boys mildly affected gait pattern 0 boys tiptoeing gait pattern Table Of Excess body mass therefore presumably plays important role affecting gait DMD A systematic review showed strong evidence increased internal external pelvis range motion increased hip internal rotation increased moments powers hip knee ankle moderate evidence increased step width children overnight obesity compared normal weight peers In order ensure stability forward progression suggested excess body mass requires muscles produce higher moments Unlike children adjust increase body mass using muscles effectively increasing muscle strength progressive muscle weakness boys DMD limits ability cope increased load Besides excess body mass muscle contracture could impose additional strain necessitates even muscle strength ensure forward progression Moreover excess body mass may also result flexible rigid deformities Is flexible feet larger arch drops lower arch rigidity bearing weight previously reported pediatric obesity55 His combination gastrocnemius contracture restricting ankle dorsiflexion considered likely causes abnormally increased motion midfoot e midfoot break examples provided Fig Of could captured applied simplistic foot model Met midfoot break indeed observed video boys Additionally appears link increasing BMI Fig Of There discernible sequel aerial casting could contribute midfoot break however nocturnal splitting may potentially exerted influence Fig Of A midfoot break DMD never reported rather unexpected finding Usually tibialis posterior contracted equinovarus deformity present prevents version increased dorsiflexion midfoot It possible overall contracture tibialis posterior develops later phase disease boys DMD spending less time bearing weight time sitting wheelchair 2 therefore equinovarus deformity may reported frequently non ambulatory boys Nutritional care aiming prevention overnight obesity may potential improve gait pathology DMD The added value results compared previous studies 30 lies comprehensive mapping comparison entire kinetic kinetic waveforms across gait patterns well gait pattern children Additionally trunk kinematics previously lacking included analysis Consequently findings provide detailed insight previous studies focused solely single global functional outcome 6MWT NSAA global gait parameter GDI 30 specific gait parameter certain points GC23 Is result insight DMD gait pathology enhanced Additionally link current classification scores NSAA 6MWT highlight clinical relevance Figs Of Of Boys flexion pattern tend lower NSAA scores cover shorter distances 6MWT compared two gait patterns Moreover boys exhibiting flexion pattern lost amputation shortly last measurement session Fig Of These findings emphasize clinical importance sneering boys DMD away flexion pattern rousing addressing midfoot break However premature state current classification clinically useful findings previous studies 30 due limited number participants severely affected gait patterns Additionally overlap two affected gait patterns It therefore yet clear whether tiptoeing gait pattern valid separate gait pattern whether tiptoeing flexion gait patterns considered one affected gait pattern His highlight complexity continuous changes gait patterns especially late phases Therefore future studies longer follow loss amputation larger number severely affected boys needed verify sensitivity findings prior transfer daily clinic Nevertheless classification based detailed gait data across entire waveforms may ultimately offer greater utility potential classification relying solely single outcome measures Preliminary longitudinal explorations The longitudinal evolution gait pattern gait pattern within participants explored Fig Of Overlap gait patterns particular 3DGA session displayed coloring markets figure The classification session interpreted according majority assignment However sessions overlap could also indicate intermediate stage gait patterns Twenty one boys consistently demonstrated gait pattern follow thus show transition another gait pattern Specifically 16 patients stayed mildly affected gait pattern four patients flexion pattern one patient tiptoeing gait pattern Transitions mildly affected flexion gait pattern detected five patients Three five patients showed period assigned mildly affected flexion gait patterns could indicate intermediate stage Good adherence nighttime ankle foot outhouses almost aerial casting except one patient consistent participation clinical trials disease edifying meditation four patients reported group Additionally transition often observed case increasing BMI Fig Of especially four patients Two patients transition mildly affected tiptoeing gait pattern Interestingly participants adhere nighttime ankle foot outhouses One received aerial casting twice participated clinical trial disease edifying meditation One patient good adherence nighttime ankle foot orthosis participation clinical trial disease edifying meditation first showed transition mildly affected flexion gait pattern demonstrated tiptoeing flexion gait patterns Lastly defiant trajectory detected one patient nonadherence nighttime ankle foot orthosis participation clinical trial disease edifying meditation first transition flexion tiptoeing gait pattern demonstrated tiptoeing flexion gait patterns However overlap detected sessions could indicate intermediate stage two gait patterns The causes transitions deduced medical clinical background participants The current data suggest transition tiptoeing gait pattern occurs case nonadherence nighttime ankle foot orthosis transition flexion gait pattern occurs case increasing BMI However future research investigate medical intervention clinical background well underlying impairment progressive muscle weakness contracture contribute progressive gait pathology boys DMD

듀셴 근육병(DMD)을 가진 소년들의 보행 패턴을 동질적인 그룹으로 분류하는 것은 의료 제공자 간의 의사소통, 임상 의사 결정 및 임상 시험 설계를 향상시킬 수 있습니다. 서덜랜드의 분류는 40년 전에 개발되었습니다. 그 이후로, 최신 의료 치료가 개선되었고 DMD를 가진 소년들은 이제 더 오래 걸을 수 있게 되었습니다. 따라서, 보행 분류는 업데이트가 필요합니다. 전반적인 목표는 최신의 유효한 DMD 보행 분류를 개발하는 것이었습니다. 총 137회의 3차원 보행 분석 세션이 4.6~17세 사이의 DMD를 가진 30명의 소년들에서 수집되었습니다. 세 가지 클래스가 구분되었으며, 이는 보행 이상의 심각성이 증가함에 따라 부분적으로만 일치했습니다. 경미하게 영향을 받은 패턴 외에도, 두 가지 더 심각하게 영향을 받은 보행 패턴이 발견되었는데, 바로 발끝 걷기 패턴과 뚜렷한 전방 골반 기울임과 후방 몸통 기울임이 있는 굴곡 패턴으로, 각각 발목 또는 근위부 분절/관절에서 가장 심각한 이상을 보였습니다. 서덜랜드의 분류와 현재 분류 간의 일치도는 낮아, 현재의 최신 의료 치료 상태에서 보행 병리가 변했다는 것을 시사합니다. 그러나, 특히 두 가지 더 영향을 받은 클래스 사이에서 클래스 간의 중복은 지속적인 보행 변화의 복잡성을 강조합니다. 따라서, DMD를 가진 개별 소년들을 클래스로 분류할 때 주의가 필요합니다.

Classifying gait patterns into homogeneous groups could enhance communication among healthcare providers, clinical decision making and clinical trial designs in boys with Duchenne muscular dystrophy (DMD). Sutherland’s classification has been developed 40&nbsp;years ago. Ever since, the state-of-the-art medical care has improved and boys with DMD are now longer ambulatory. Therefore, the gait classification requires an update. The overall aim was to develop an up-to-date, valid DMD gait classification. A total of 137 three-dimensional gait analysis sessions were collected in 30 boys with DMD, aged 4.6–17&nbsp;years. Three classes were distinguished, which only partly aligned with increasing severity of gait deviations. Apart from the mildly affected pattern, two more severely affected gait patterns were found, namely the tiptoeing pattern and the flexion pattern with distinct anterior pelvic tilt and posterior trunk leaning, which showed most severe deviations at the ankle or at the proximal segments/joints, respectively. The agreement between Sutherland’s and the current classification was low, suggesting that gait pathology with the current state-of-the-art medical care has changed. However, overlap between classes, especially between the two more affected classes, highlights the complexity of the continuous gait changes. Therefore, caution is required when classifying individual boys with DMD into classes.

듀센 근육병을 가진 성장기 아동의 보행 분류 | 과학 보고서