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Intranet.karolinskaeducation.ki.se
Effect of joint injections in children with juvenile idiopathic arthritis:evaluation by 3D-gait analysis
E Brostro¨m, S Hagelberg and Y Haglund-A
Department of Woman and Child Health, Karolinska Institute, Astrid Lindgren Children’s Hospital, Stockholm, Sweden
˚ kerlind Y. Effect of joint injections in children with juvenile
idiopathic arthritis: evaluation by 3D-gait analysis. Acta Pædiatr 2004; 93: 906–910. Stockholm. ISSN 0803-5253
Aim: To investigate how gait patterns change after intra-articular corticosteroid injections (ICIs) inthe lower extremities. Methods: Eighteen children, aged 5–16 y, with juvenile idiopathic arthritis(JIA) and lower extremity involvement participated in the study. Sixty-four joints in the lowerextremities were treated with ICIs. The Visual Analogue Scale (VAS, 0–100 mm) was used toassess pain. A 3D motion analysis system and two force plates were used to measure gaitparameters, kinematics and kinetics. The first gait analysis was performed before treatment withICIs, and a second one was done 8–17 d after treatment. Results: The participants’ average ratingof pain decreased from 26 mm on the VAS before ICI to 11 mm (p = 0.001) after treatment. Theself-chosen walking velocity was significantly faster (p = 0.02) after treatment. The range of kneeand ankle joint angles during gait increased significantly (p = 0.03 and 0.04) after treatment. Atloading response, the hip extension moment increased (p = 0.01) as did knee flexion moment, andplantar flexion moment at pre-swing increased significantly (p = 0.02 and 0.002) after treatment. The ankle also generated more power (p = 0.005) after treatment. Conclusion: The study shows positive effects of treatment with ICIs in the lower extremities—especially regarding pain, walking velocity and joint moments. The data indicate that ICItreatment influences the gait pattern also in joints that have not been injected. Key words: Gait, juvenile rheumatoid arthritis, kinematics, kinetics, locomotion Eva Brostro¨m, Department of Woman and Child Health, Astrid Lindgren Children’s Hospital,Q2:07, SE-171 76 Stockholm, Sweden (Tel. 46 8 5177 7636, fax. 46 8 5177 7351, e-mail. Eva.brostrom@kbh.ki.se)
The lower extremities are often affected in juvenile
and leg length (9, 12–14). Various studies have shown
idiopathic arthritis (JIA). This can lead to functional
that children with JIA experience pain and stiffness
disabilities, with deviations from the normal gait
together with reduced physical capability and altered
pattern, including restricted joint motion, velocity,
limping and reduction in step length. Long duration of
Three dimensional (3D) gait analyses, including
active disease is also associated with a reduction in
kinematics and kinetics, provide more information
height (1–4), discrepancy in leg length, and shortening
about gait changes, such as joint angles and moments,
of muscle and tendon length that causes joint flexion
which are impossible to quantify in a standard clinical
contractures (5–7). Early use of intra-articular cortico-
setting. The kinematics shows the joint movement, and
steroid injections (ICIs) in the joint rapidly resolves
the kinetics describes the forces involved in movement
synovitis, protects against joint deformity and alleviates
(e.g. ground reaction forces, joint moments, and joint
pain, thus creating a good opportunity for physiotherapy
powers). By examining kinetics, the mechanisms of gait
and rehabilitation (8). Furthermore, by using ICIs, leg-
deviation can be described. Gait analysis has the
length discrepancies may be avoided, which, in turn,
potential to measure pathological changes in ambula-
reduces the need for systemic treatment with steroids
tion (15, 16) and can provide important information
about children’s gait patterns, thus helping physicians to
Walking is a task that we seek to understand better
make the correct decisions regarding treatments that
because it is one of the most fundamental physical
include, for example, ICI and physical therapy (12, 17,
functions of the human being. In earlier studies by
18). Early use of gait analysis can be instrumental in
others and by ourselves (10, 11) it was identified that
discovering developments of potentially destructive gait
children with JIA generally walked more slowly than
their healthy peers, that walking velocity varies with
The aim of this study was to determine the effects of
age, and, more importantly, with factors such as height
ICI treatment in the lower limbs by using 3D gait
2004 Taylor & Francis. ISSN 0803-5253
Joint injections in children with JIATable 1. Demographic data showing mean (SD) for children with JIA
England). Thirty-four reflective markers (25 mm) were
attached bilaterally on the subject’s skin at the head,shoulders, arms, pelvis, legs and feet according to the
biomechanical gait model (Plugin Gait, Vicon Motion
Systems). A total of three completed walking trials were
performed for the kinematics and time-distance par-
ameters. Two force plates (Kistler, Basel, Switzerland)
along the walkway were used to measure ground
reaction forces to produce joint kinetic information
using inverse dynamics. One to three completed
walking trials were performed to measure kinetics. A
walking trial was considered completed if the subject’s
right or left foot made a clean contact on the force plate. The children were advised not to walk for 24 h and to
avoid physical exercise for one week after ICItreatment. The second gait analysis was performed 8–17 d after treatment with ICI. To imitate the conditions
analysis to describe joint angles and kinetics during
at the first gait analysis, the same procedure was
locomotion in the hip, knee and ankle.
followed and the same examiner (EB) performed theclinical measurements and marker placements.
Kinematics, kinetics, and time-distance parameters
Eighteen children aged between 5 and 16 y with JIA
were derived using the Vicon PlugIn Gait model. The
participated in the study. All subjects had been
lower body was modelled as 7 segments (pelvis, 2
diagnosed according to the International League
thighs, 2 shanks, 2 feet). Ground reaction forces,
Against Rheumatism (ILAR) classification system
moments and power were normalized to body weight.
(20), and suffered from lower extremity involvement
Stride parameters were normalized to height. An
and polyarthritis. All patients were recruited from the
ensemble, or point-to-point average gait cycle was
clinic of Paediatric Rheumatology, Astrid Lindgren
generated, from which gait patterns of the hip, knee and
Children’s Hospital, Karolinska Hospital in Stockholm.
foot joint angles and joint moments were derived both
Two patients were excluded because of medical
before and after treatment with ICI. Joint power was
conditions that prevented them from returning for the
defined as the scalar product of the moment and the joint
second gait analysis. The participants were independent
angular velocity, and an entire gait cycle was defined
walkers and had been injected with methylprednisolone
from first contact to foot contact of the same limb
acetate (Depo-medrol2) in 1 to 10 joints in the lower
extremities. Our policy is to inject any joint that is
The following peak values from the subjects’
active (with synovitis). During the study, 64 active
ensemble gait cycle were analysed: hip flexion and
joints were treated uni- or bilaterally with ICI (Table 1).
extension; maximum hip flexion, extension and abduc-
The subjects’ characteristics are presented in Table 1.
tion moments; maximum knee flexion and extension;
The database from our gait laboratory with 21 healthy
maximum knee flexion, extension and varus moments;
children between 5 and 14 y of age functioned as
maximum ankle plantar flexion and dorsiflexion angles;
controls when interpreting the data. The Research
maximum plantar flexion and dorsiflexion moments;
Ethics Committee of the Karolinska Hospital approved
maximum power generation and absorption at the ankle.
the study. Verbal and written information was given tothe children and their parents. ProcedureAll the children were asked to rate their level of pain ona visual analogue scale (VAS, 0–100 mm, using amoveable bar) prior to, during, and after the procedurein order to record increased pain. VAS has proven to bea reliable tool for measuring the intensity of pain inchildhood (21). The subjects walked barefoot on a 7.5-m-long walkway at a self-chosen velocity. Movementrecordings were done with a 6-camera 3D motion
Fig. 1. Normal gait cycle defined from initial heel contact to heel
analysis system (Vicon, Motion System, Oxford,
Table 2. Mean values (SD) for gait parameters pre- and post-
and velocity before and after treatment. All time-
treatment with intra-articular corticosteroid injections in children
distance parameters are presented in Table 2. Hip joint angles. The hip range of motion (maximum
hip flexion to maximum extension) did not show any
significant difference after treatment. The average was
38° before and after ICI (range 14°–55°).
JIA: juvenile idiopathic arthritis; ICI: intra-articular corticosteroid
Hip moments. The hip extension moment, which takes
place during the loading response (the first 5–10% of thegait cycle), increased significantly (p = 0.01) (Table 3)after treatment with ICI, even if the subjects were not
treated in the hip joint. There were no significant
A two-way analysis of variance (ANOVA), repeated
differences between left and right hip joint moments
measures design, was used to assess the kinematics and
and there was no significant difference in peak hip
kinetic data from the 3D-gait analysis. The factors were
flexion moment after treatment (Table 3). Two children
side (left and right) and treatment (before and after ICI).
with JIA were injected bilaterally in the hip joint and
For time and stride variables, non-parametric statistics
two were injected only in the right hip (Table 3).
(Wilcoxon’s matched pairs test) were used to test forsignificance. Friedman ANOVA by rank test was used
Knee joint angles. The knee range of motion (maximum
to identify pain (VAS) before and after ICI treatment.
knee extension to maximum flexion) during gait
The level of significance was set to p 0.05. All
increased significantly (p = 0.03) from 50° (range 33°–
statistical analyses were performed using Statistica 6.0
63°) to 54° (range 39°–63°) after treatment. Knee moments. Of the entire group of children with JIAthat were injected in the lower extremities, none of the
subjects showed a significant difference in peak knee
extension moments at loading response after treatment
The participants rated their pain before the ICI at 26 mm
with ICI (Table 3). There was a significant increase
(median value, range 0–69 mm) on the VAS. After
(p = 0.02) in peak knee flexion moment at pre-swing
(50% of the gait cycle) after treatment with ICI. There
(p = 0.001) reduced to 11 mm (range 0–32 mm).
were no significant differences between left and rightknee joints. No significant differences were shown inthe frontal moment at initial contact and at pre-swing at
horizontal level after treatment with ICI in the knee
The participants showed a significantly faster self-
chosen walking velocity after treatment with ICI
Seven subjects were injected with ICI in the knee
(p = 0.02). There was no correlation between pain rating
joint, five bilaterally and two unilaterally (Table 3). Table 3. Mean joint moments (units are Nm/kg) in the sagittal plane. These refer to mean values for the whole JIA population (SD) and theinjected joints before and after ICI treatment and non-injected joints. Data were obtained from both the left and right gait cycles. Joint injections in children with JIAAnkle joint angles. The ankle joint angle range (maxi-
two other studies (27, 28) it has been shown that
mum dorsiflexion to maximum plantar flexion) during
children with JIA have a moderate to large impairment
gait increased significantly (p = 0.04) from 19° to 22°
in their cardio-respiratory fitness compared with healthy
children. Knowing this, it is important to create exerciseopportunities for children with JIA so that they can
Ankle moments. The ankle plantar flexion moment at
participate in physical activities and sports.
pre-swing showed a significant difference (p = 0.002)
Children with JIA have been reported to use lower
while dorsiflexor moment at loading response did not
self-chosen walking velocity, with reduced vertical
change after treatment with ICI (Table 3).
ground reaction forces at heel strike and push off,
Thirteen children were injected in the right foot and
compared with healthy, age-matched controls (9). Other
11 were injected in the left foot (Table 3); 8 children
studies have pointed out the importance of normalizing
were injected unilaterally and 8 were injected bilaterally
walking velocity to height to allow comparisons
between children of the same age with and withoutJIA (10, 11, 26). In their study, Fairburn et al. (19) found
Power. Ankle power increased significantly (p = 0.005)
that children with JIA showed abnormal gait patterns
at 50% of the gait cycle (stance phase) after treatment
even though the joint activities were low.
The 3D-gait analysis data showed increased range
between maximum flexion and extension angles duringlocomotion in the knee and ankle. This is important
because it indicates that the children with JIA have theopportunity to change their ingrained gait patterns.
This study has shown the positive effects of treatment
Children and adults with arthritis often suffer from foot
with ICI in the lower extremities—especially on pain,
problems, categorized as pronated foot, synovitis, and
walking velocity and joint moments. Furthermore, and
have a diminished range of motion in the ankle and toe
very importantly, the data indicates that ICI treatment
valgus (29). This indicates that foot problems are
influences the gait pattern even in joints not being
common in the JIA population, underscoring the need
treated. The aim of this study was to evaluate gait after
for thorough evaluation and management of physical
treatment, using the patients as their own controls and
not to compare them with untreated children with JIA or
The hip extension joint moment at loading response,
knee flexion joint moment at pre-swing and ankle
To our knowledge, this is the first study that has been
plantar flexion joint moments at stance showed in-
undertaken to evaluate gait pattern after treatment with
creased values after treatment with ICI. However, we
ICI. Three-dimensional gait analysis is a well-estab-
found that all joint moments in children with JIA
lished method enabling highly objective and reliable
showed decreased values in comparison with those of
evaluation of gait in both healthy and diseased popula-
healthy children in our database. This study indicates
tions (12, 18, 22). It is also important to bear in mind
that the plantar flexor moment increased after treatment
that the pharmaceutical methyl-prednisolone acetate
with ICI, which is important in order to manage toe-off.
(Depo-medrol2) we used does not have as lasting an
The main muscle groups that are active at the ankle
effect as triamcinolone hexacetonide (Lederspan2)
throughout stance are the plantar flexors (triceps surae).
(23), which was not available on the market at the time
We know from our earlier studies (30) that children with
of this study. Our clinical experience is that ICIs in
JIA are weaker in the plantar flexors compared with
general have a good and prompt effect on the treated
joints. The gait pattern of children with JIA is com-
To evaluate the muscle action during a movement,
plicated by compensatory gait alternations, resulting
we also need to calculate the power, which tells us how
from joint pain, stiffness, and in some cases joint
the muscle group is contracting (isometrically, concen-
deformity. It has been shown that the kinematics of the
trically or eccentrically). It does not, however, tell us in
hip, knee and ankle joints is clearly related to walking
detail how the muscle contracts. When we assessed the
velocity (24), and that both the profile and magnitude of
power (W/kg) we found that the hip and knee values
the external ground reaction forces are velocity depen-
were almost normal (compared with healthy children in
dent (25, 26). A higher walking velocity generally
our database), while the ankle powers were decreased
results in elevated vertical and anterior–posterior
(2.04 watt vs 2.95 watt) in children with JIA.
ground reaction forces, which consequently require
In conclusion, this group of children with JIA showed
greater lower-limb muscle strength. The participant’s
significant positive changes in their gait patterns after
self-chosen walking velocity in this study increased
treatment with ICI in the lower extremities measured by
significantly after treatment, which is important for
3D-gait analysis. These results point out how important
daily activities. There was no relationship between pain
it is for physicians to use ICI treatment, which is
rating and velocity in this study, perhaps because the
preferable to systemic steroids. Furthermore, this group
group was too small to show statistical correlation. In
of children was able to absorb and generate more
muscle power after ICI. All this information is of
spatial parameters of gait in children. II: Pathological gait. Dev
interest in the interpretation of walking. This is
clinically important because the disease often affects
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lower extremity kinematics during level walking. J Orthop Res
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Acknowledgements.—The study was funded by grants from The
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Swedish Rheumatism Association, the Vardal Foundation for Health
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Received July 11, 2003; revisions received Sept. 18, 2003; accepted
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