The gait of children with and without cerebral palsy: work, energy, and angular momentum

This paper describes a method to characterize gait pathologies like cerebral palsy using work, energy, and angular momentum. For a group of 24 children, 16 with spastic diplegic cerebral palsy and 8 typically developed, kinematic data were collected at the subjects self selected comfortable walking speed. From the kinematics, the work-internal, external, and whole body; energy-rotational and relative linear; and the angular momentum were calculated. Our findings suggest that internal work represents 53% and 40% respectively of the whole body work in gait for typically developed children and children with cerebral palsy. Analysis of the angular momentum of the whole body, and other subgroupings of body segments, revealed a relationship between increased angular momentum and increased internal work. This relationship allows one to use angular momentum to assist in determining the kinetics and kinematics of gait which contribute to increased internal work. Thus offering insight to interventions which can be applied to increase the efficiency of bipedal locomotion, by reducing internal work which has no direct contribution to center of mass motion, in both normal and pathologic populations.     

Effect of exercise intensity and duration on postexercise metabolism

Data are reported on the net recovery O2 consumption (VO2) for nine male subjects (mean age 21.9 yr, VO2max 63.0 ml.kg-1.min-1, body fat 10.6%) used in a 3 (independent variables: intensities of 30, 50, and 70% VO2max) x 3 (independent variables: durations of 20, 50, and 80 min) repeated measures design (P less than or equal to 0.05). The 8-h mean excess postexercise O2 consumptions (EPOCs) for the 20-, 50-, and 80-min bouts, respectively, were 1.01, 1.43, and 1.04 liters at 30% VO2max (6.8 km/h); 3.14, 5.19, and 6.10 liters at 50% VO2max (9.5 km/h); and 5.68, 10.04, and 14.59 liters at 70% VO2max (13.4 km/h). The mean net total O2 costs (NTOC = net exercise VO2 + EPOC) for the 20-, 50-, and 80-min bouts, respectively, were 20.48, 53.20, and 84.23 liters at 30% VO2max; 38.95, 100.46, and 160.59 liters at 50% VO2max; and 58.30, 147.48, and 237.17 liters at 70% VO2max. The nine EPOCs ranged only from 1.0 to 8.9% of the NTOC (mean 4.8%) of the exercise. These data, therefore, indicate that in well-trained subjects the 8-h EPOC per se comprises a very small percentage of the NTOC of exercise.     

Physiological strain due to load carrying in heavy footwear.

To determine the effects of wearing heavy footwear on physiological responses five male and five female subjects were measured while walking on a treadmill (4, 5.25, and 6.5 km.h-1) with different external loads (barefooted, combat boots, and waist pack). While walking without an external load the oxygen uptake, as a percentage of maximal oxygen uptake (%VO2max) of the men increased from 25% VO2max at 4 km.h-1 to 31% VO2max at 5.25 km.h-1 and to 42% VO2max at 6.5 km.h-1. The women had a significantly higher oxygen uptake of 30%, 40%, and 55% VO2max, respectively. In the most strenuous condition, walking at 6.5 km.h-1 with combat boots and waist pack (12 kg), the oxygen uptake for the men and women amounted to 53% and 75% VO2max, respectively. The heart rate showed a similar response to the oxygen uptake, the women having a heart rate which was 15-40 beats.min-1 higher than that of the men, depending on the experimental condition. The perceived exertion was shown to be greatly dependent on the oxygen uptake. From the results a regression formula was calculated predicting the oxygen uptake depending on the mass of the footwear, walking speed and body mass. It was concluded that the mass of footwear resulted in an increase in the energy expenditure which was a factor 1.9-4.7 times greater than that of a kilogram of body mass, depending on sex and walking speed.     

The relationship between changing body height and growth related changes in maximal aerobic power

In order to analyse the relationship between maximal aerobic power (VO2max) and height, body mass and lean body mass a multi-longitudinal survey was conducted on three different age groups of randomly selected children from a small Czech community. Beginning at the initial ages of 8, 12 and 16 years subjects were subsequently retested three times at 2-year intervals. At overlapping ages there were no differences in the various age groups between height and VO2max. By utilizing mean values for the various parameters at specific calendar ages a growth curve was constructed for each sex for the age range 8-20 years. The values were compared with longitudinal studies in various countries and no substantial differences were found. When VO2max was then compared to height, body mass and lean body mass it was apparent that the almost linear relationship with height was the most precise. In addition the children remained, generally speaking, in their same rank order for VO2max for the three different age groupings.     

Gait Pattern Differences between Children with Mild Scoliosis and Children with Unilateral Cerebral Palsy

This study was conducted to investigate the effects of asymmetrical body posture alone, i.e., the effects seen in children with mild scoliosis, vs. the effects of body posture control impairment, i.e., those seen in children with unilateral cerebral palsy on gait patterns. Three-dimensional instrumented gait analysis (3DGA) was conducted in 45 children with hemiplegia and 51 children with mild scoliosis. All the children were able to walk without assistance devices. A set of 35 selected spatiotemporal gait and kinematics parameters were evaluated when subjects walked on a treadmill. A cluster analysis revealed 3 different gait patterns: a scoliotic gait pattern and 2 different hemiplegic gait patterns. The results showed that the discrepancy in gait patterns was not simply a lower limb kinematic deviation in the sagittal plane, as expected. Additional altered kinematics, such as pelvic misorientation in the coronal plane in both the stance and swing phases and inadequate stance phase hip ad/abduction, which resulted from postural pattern features, were distinguished between the 3 gait patterns. Our study provides evidence for a strong correlation between postural and gait patterns in children with unilateral cerebral palsy. Information on differences in gait patterns may be used to improve the guidelines for early therapy for children with hemiplegia before abnormal gait patterns are fully established. The gait pathology characteristic of scoliotic children is a potential new direction for treating scoliosis that complements the standard posture and walking control therapy exercises with the use of biofeedback.     

Crouch severity is a poor predictor of elevated oxygen consumption in cerebral palsy

Children with cerebral palsy (CP) expend more energy to walk compared to typically-developing peers. One of the most prevalent gait patterns among children with CP, crouch gait, is often singled out as especially exhausting. The dynamics of crouch gait increase external flexion moments and the demand on extensor muscles. This elevated demand is thought to dramatically increase energy expenditure. However, the impact of crouch severity on energy expenditure has not been investigated among children with CP. We evaluated oxygen consumption and gait kinematics for 573 children with bilateral CP. The average net nondimensional oxygen consumption during gait of the children with CP (0.18 ± 0.06) was 2.9 times that of speed-matched typically-developing peers. Crouch severity was only modestly related to oxygen consumption, with measures of knee flexion angle during gait explaining only 5–20% of the variability in oxygen consumption. While knee moment and muscle activity were moderately to strongly correlated with crouch severity (r² = 0.13–0.73), these variables were only weakly correlated with oxygen consumption (r² = 0.02–0.04). Thus, although the dynamics of crouch gait increased muscle demand, these effects did not directly result in elevated energy expenditure. In clinical gait analysis, assumptions about an individual’s energy expenditure should not be based upon kinematics or kinetics alone. Identifying patient-specific factors that contribute to increased energy expenditure may provide new pathways to improve gait for children with CP.     

Locomotion studies as an aid in clinical assessment of childhood gait.

A clinical locomotion laboratory has been developed to provide quantitative information in the management of gait disorders. The biomedical engineering development of this system identified two major clinical constraints: (a) the need for instrumentation that would not alter the natural gait of the patient and (b) the need for data-processing techniques that would permit analysis and correlation of the large volume of electromyographic (EMg) and kinematic information. The net result has been a unit that incorporates a multichannel telemetry system to capture the EMG and foot-switch information and a television computer system to handle the kinematic information. Gait studies on children with hemiparesis, muscular dystrophy and cerebral palsy have yielded quantitative EMG and kinematic information on the pathomechanics of ambulation in these disorders. Because the information obtained is quantitative, an accurate measure of improvement (or lack of it) after treatment can be documented. Therefore, the locomotion laboratory may have an important role in the preoperative and postoperative evaluation of children whose abnormal gait may require surgical corrective procedures or rehabilitative treatment including the use of prostheses or orthoses.     

The relationship between lower limb muscle volume and body mass in ambulant individuals with bilateral cerebral palsy

Background

Individuals with cerebral palsy have smaller muscle volumes normalised to body mass than their typically developing peers. The aim of this study is to investigate the relationship between lower limb muscle volume and body mass in young people with bilateral cerebral palsy and their typically developing peers.

Methods

Twenty-five participants with bilateral cerebral palsy (aged 14.7±3.0 years, GMFCS level I-III) and 25 of their typically developing peers (aged 16.8±3.3 years) took part in this study. None of the participants had undergone orthopaedic surgery, botulinum toxin injections, or serial casting in the previous year. All participants underwent magnetic resonance imaging of both lower limbs. Nine major muscles of each lower limb were individually manually segmented and the muscle volumes calculated.

Results

Body mass and total lower limb muscle volume were significantly linearly related in both the cerebral palsy (R² = 0.75, p<0.001) and typically developing (R² = 0.77, p<0.001) groups. The slope of the relationship between muscle volume and body mass was significantly shallower in the cerebral palsy group compared to the typically developing group (p=0.007).

Conclusions

This cross-sectional study suggests that the increase in size of lower limb muscles relative to body mass is reduced in adolescents and young adults with cerebral palsy. Longitudinal studies are required to further investigate altered muscle growth trajectories in this group and their impact on long-term mobility.

     

Some simple multiple linear regression equations for estimation of maximal aerobic power in healthy Indian males

An attempt has been made to evolve some simple multiple linear regression equations for the prediction of VO2 max from body weight, time for 3.2 km run and exercise dyspnoeic index ( DIstd Ex%). The predictor variables have been selected by examining the product moment correlations of body weight, relative body weight indices, time for 3.2 km run, chest expansion, height, and DIstd Ex% with VO2 max, based on data collected on 320 healthy Indian males (17-22 years). It has been observed that body weight, time for 3.2 km run and DIstd Ex% attained maximum correlations with VO2 max. Thus, two regression equations with two and three predictor variables have been established in this paper to predict VO2 max. The first regression equation yielded a multiple correlation of 0.608 (P less than 0.001) with a standard error of 0.214 1 X min-1. In this equation, body weight and time for 3.2 km run were considered as significant predictors. To increase the precision of this equation, another multiple linear regression equation based on body weight, time for 3.2 km run and DIstd Ex% as predictors has been developed. This equation yielded a multiple correlation of 0.658 (P less than 0.001) with a standard error of 0.204 1 X min-1. Applications of these regression equations will be of practical importance to biomedical scientists engaged in the development of a simple procedure for indirect assessment of VO2 max, and may serve well as preliminary screening procedures for personnel selection.     

Changes in physical activity and fitness after 3 months of home Wii Fit™ use

The purpose of this study was to examine changes in physical activity and fitness variables in members of 8 volunteer families after 3 months of home use of the Wii Fit? interactive video game. Pre and postintervention measurements were obtained from 21 subjects relative to physical activity (5 days of accelerometry), aerobic fitness (graded treadmill test), muscular fitness (push-ups), flexibility (sit-and-reach test), balance (composite equilibrium score), and body composition (body mass index and % body fat). Use characteristics of the Wii Fit? device were also determined. A series of 2 (age group) × 2 (time) repeated measures analyses of variance were conducted to assess changes over time and between adults and children. Three months of home Wii Fit? use revealed no significant age group × time interactions or main effects of group or time for daily physical activity, muscular fitness, flexibility, balance, or body composition. An age group × time interaction (p = 0.04) was observed in peak VO2 (ml·kg(-1)·min(-1)) with children displaying a significant (p = 0.03) increase after 3 months of Wii Fit? use, whereas adults showed no significant (p = 0.50) change. Daily Wii Fit? use per household declined by 82% (p < 0.01) from 21.5 ± 9.0 min·d(-1) during the first 6 weeks to 3.9 ± 4.0 min·d(-1) during the second 6 weeks. Most measures of health-related fitness in this exploratory study remained unchanged after 3 months of home use of the popular Wii Fit? whole-body movement interactive video game. Modest daily Wii Fit? use may have provided insufficient stimulus for fitness changes.     

较深麻醉下拔管对脑瘫患儿行选择性脊神经后根切断术后躁动的影响

摘要 目的：探讨较深麻醉下拔管对脑瘫患儿行选择性脊神经后根切断术后躁动的影响。方法：2017年8月到2019年2月在本院进行诊治的脑瘫患儿89例,根据麻醉方法的不同把患儿分为观察组49例与对照组40例。所有患儿都给予选择性脊神经后根切断术治疗与全身麻醉。观察组在麻醉维持中静脉持续泵注丙泊酚进行较深麻醉下拔管,对照组吸入七氟烷进行较深麻醉下拔管,观察两组患儿术后躁动情况。结果：两组的麻醉时间、睁眼时间与拔管时间等对比差异无统计学意义(P>0.05)。观察组术后躁动发生率为2.0 %,显著低于对照组的15.0 % (P<0.05)。两组术后1个月的适应与语言行为评分都显著高于术前1 d (P<0.05),且观察组也显著高于对照组 (P<0.05)。两组术后1个月的大脑中动脉收缩期峰值流速(Peak systolic flow velocity, Vs)、舒张末血流速度(End-diastolic blood flow velocity,Vd)都显著高于术前1 d (P<0.05),且观察组也显著高于对照组(P<0.05)。结论：较深麻醉下拔管在脑瘫患儿行选择性脊神经后根切断术的应用能减少术后躁动的发生,且不影响麻醉效果,从而提高治疗效果,改善大脑血流动力学状况。     

The effect of corrective surgery on energy expenditure during ambulation in children with cerebral palsy

Mechanical efficiency, heart rate, blood lactate, and some other variables were studied in six children with cerebral palsy who walked on a treadmill before and after corrective surgery. During each test, conducted at each child's naturally selected speed, two situations were studied: steady state level walking for 9 min, and then walking at an increasing inclination up to 20% for another 10 min. During the test the subjects were allowed to hold on to a handrail to eliminate the risk of falling off the treadmill. The corrective surgery resulted in a 5% reduction in oxygen consumption per kg body mass during level walking. The subjects' levels of physical fitness, as estimated from oxygen pulse, however, were unchanged. These results are indicative of a biomechanical improvement due to the corrective surgery. While walking at a 20% inclination the subjects off loaded themselves to different degrees on the handrail which influenced the results. Their feeling of exhaustion at this load was probably due to local factors, since heart rate was well below maximal values, and blood lactate, respiratory exchange ratio and ventilatory equivalent also indicated that they were below their anaerobic thresholds (50-60% of maximal oxygen uptake).     

Effects of a concurrent strength and endurance training on running performance and running economy in recreational marathon runners

The purpose of this study was to investigate the effects of a concurrent strength and endurance training program on running performance and running economy of middle-aged runners during their marathon preparation. Twenty-two (8 women and 14 men) recreational runners (mean ± SD: age 40.0 ± 11.7 years; body mass index 22.6 ± 2.1 kg·m?2) were separated into 2 groups (n = 11; combined endurance running and strength training program [ES]: 9 men, 2 women and endurance running [E]: 7 men, and 4 women). Both completed an 8-week intervention period that consisted of either endurance training (E: 276 ± 108 minute running per week) or a combined endurance and strength training program (ES: 240 ± 121-minute running plus 2 strength training sessions per week [120 minutes]). Strength training was focused on trunk (strength endurance program) and leg muscles (high-intensity program). Before and after the intervention, subjects completed an incremental treadmill run and maximal isometric strength tests. The initial values for VO2peak (ES: 52.0 ± 6.1 vs. E: 51.1 ± 7.5 ml·kg?1·min?1) and anaerobic threshold (ES: 3.5 ± 0.4 vs. E: 3.4 ± 0.5 m·s?1) were identical in both groups. A significant time × intervention effect was found for maximal isometric force of knee extension (ES: from 4.6 ± 1.4 to 6.2 ± 1.0 N·kg?1, p < 0.01), whereas no changes in body mass occurred. No significant differences between the groups and no significant interaction (time × intervention) were found for VO2 (absolute and relative to VO2peak) at defined marathon running velocities (2.4 and 2.8 m·s?1) and submaximal blood lactate thresholds (2.0, 3.0, and 4.0 mmol·L?1). Stride length and stride frequency also remained unchanged. The results suggest no benefits of an 8-week concurrent strength training for running economy and coordination of recreational marathon runners despite a clear improvement in leg strength, maybe because of an insufficient sample size or a short intervention period.     

Oxygen cost of exercise hyperpnea: implications for performance.

We addressed two questions concerned with the metabolic cost and performance of respiratory muscles in healthy young subjects during exercise: 1) does exercise hyperpnea ever attain a "critical useful level"? and 2) is the work of breathing (WV) at maximum O2 uptake (VO2max) fatiguing to the respiratory muscles? During progressive exercise to maximum, we measured tidal expiratory flow-volume and transpulmonary pressure- (Ptp) volume loops. At rest, subjects mimicked their maximum and moderate exercise Ptp-volume loops, and we measured the O2 cost of the hyperpnea (VO2RM) and the length of time subjects could maintain reproduction of their maximum exercise loop. At maximum exercise, the O2 cost of ventilation (VE) averaged 10 +/- 0.7% of the VO2max. In subjects who used most of their maximum reserve for expiratory flow and for inspiratory muscle pressure development during maximum exercise, the VO2RM required 13-15% of VO2max. The O2 cost of increasing VE from one work rate to the next rose from 8% of the increase in total body VO2 (VO2T) during moderate exercise to 39 +/- 10% in the transition from heavy to maximum exercise; but in only one case of extreme hyperventilation, combined with a plateauing of the VO2T, did the increase in VO2RM equal the increase in VO2T. All subjects were able to voluntarily mimic maximum exercise WV for 3-10 times longer than the duration of the maximum exercise. We conclude that the O2 cost of exercise hyperpnea is a significant fraction of the total VO2max but is not sufficient to cause a critical level of "useful" hyperpnea to be achieved in healthy subjects.(ABSTRACT TRUNCATED AT 250 WORDS)     

Case-control study of intrapartum care,cerebral palsy,and perinatal death.

OBJECTIVE--To investigate the relation between suboptimal intrapartum obstetric care and cerebral palsy or death. DESIGN--Case-control study. SETTING--Oxford Regional Health Authority. SUBJECTS--141 babies who subsequently developed cerebral palsy and 62 who died intrapartum or neonatally, 1984-7. All subjects were born at term of singleton pregnancies and had no congenital anomaly. Two controls, matched for place and time of birth, were selected for each index case. MAIN OUTCOME MEASURES--Adverse antenatal factors and suboptimal intrapartum care (by using predefined criteria). RESULTS--Failure to respond to signs of severe fetal distress was more common in cases of cerebral palsy (odds ratio 4.5; 95% confidence interval 2.4 to 8.4) and in cases of death (26.1; 6.2 to 109.7) than among controls. This association persisted even after adjustment for increased incidence of a complicated obstetric history in cases of cerebral palsy. Neonatal encephalopathy is regarded as the best clinical indicator of birth asphyxia; only two thirds (23/33) of the children with cerebral palsy in whom there had been a suboptimal response to fetal distress, however, had evidence of neonatal encephalopathy; these 23 formed 6.8% of all children with cerebral palsy born to residents of the region in the four years studied. CONCLUSION--There is an association between quality of intrapartum care and death. The findings also suggest an association between suboptimal care and cerebral palsy, but this seems to have a role in only a small proportion of all cases of cerebral palsy. The contribution of adverse antenatal factors in the origin of cerebral palsy needs further study.     

Blood flow in thigh muscle during bicycling exercise at varying work rates.

16 male subjects exercised at 25, 50, 75, 90, 100 and 120% of VO2max on a von D?beln bicycle ergometer. The muscle mass was measured in a whole body counter. Muscle blood flow (MBF) estimated from the rate of 133Xe clearance from m. rectus femoris showed a levelling-off at about 0.5 1 of blood per min and liter of muscle tissue (equal to an irrigation coefficient of 0.5 min-1) at work rates above 50 to 60% of VO2 max. This concurs with clearance data from the literature. However, when MBF is calculated from VO2, muscle mass, and reliable values for a- vo2 differences, MBF in the present subjects would: 1. Not level off before 90 to 100% VO2max, 2. reach a value of 1.0 min-1. The underestimation of MBF calculated from 133Xe clearance and the levelling-off shown by this method may be due to a systematic error inherent in the method, the 133Xe clearance being diffusion limited at high flow rates.     

Allometry of resting metabolic rate in cockroaches

1. Resting VO2 at 22.7 degrees C was 0.217 +/- 0.007 ml O2/g/hr in Nauphoeta cinerea of 0.51 +/- 0.008 g body mass. 2. Whole animal resting metabolic rate for 11 cockroach species scaled allometrically: VO2 = 0.261 M0.776. 3. Allometry of resting VO2 among cockroach species is similar to that in vertebrates, and is consistent with models based on both "elastic similarity" and "biological similitude."     

颈总动脉周围交感神经网剥脱切除术治疗学龄前脑瘫患儿的疗效及对患儿认知状况的影响

目的:探讨颈总动脉周围交感神经网剥脱切除术治疗学龄前脑瘫患儿的临床效果及对患儿认知状况影响。方法:选取2014年12月~2016年12月我院收治的学龄前脑瘫患儿84例,根据治疗方式的不同分为观察组与对照组,每组42例。对照组给予常规非手术治疗,观察组给予颈总动脉周围交感神经网剥脱切除术治疗,两组患儿均进行为期24周的随访观察。观察和比较两组的综合功能改善情况,治疗前后发育商、智商以及C因子值水平的变化。结果:观察组综合功能改善总有效率为95.24%(40/42),显著高于对照组的78.57%(33/42)(P0.05)。治疗后24周,观察组患儿的发育商值为(84.5±11.3),显著高于对照组(62.2±12.4)(P0.05);观察组患儿的智商值为(80.7±11.4),显著高于对照组(67.3±12.1)(P0.05);观察组患儿的C因子值为(12.8±4.0),显著高于对照组(9.9±3.3)(P0.05)。结论:颈总动脉周围交感神经网剥脱切除术治疗学龄前脑瘫患儿的临床效果显著,可有效改善患儿的认知状况。     

Life expectancy in children with cerebral palsy.

OBJECTIVE--To determine life expectancy of children with cerebral palsy. DESIGN--Cohort analysis, by means of register compiled from multiple sources of ascertainment, of all children with cerebral palsy born during 1966-84 to mothers resident in Mersey region. Status of children was determined by flagging through NHS central register. SUBJECTS--1258 subjects with idiopathic cerebral palsy, of whom 1251 were traced and included in analysis. MAIN OUTCOME MEASURES--Effect of functional ability (ambulation, manual dexterity, and mental ability), sex, birth weight, and gestational age on survival. RESULTS--20 year survival for whole cohort was 89.3% for females and 86.9% for males. For subjects with no severe functional disabilities 20 year survival was 99% (95% confidence interval 98% to 100%), while subjects severely disabled in all three functional groups had 20 year survival of 50% (42% to 58%). Subjects with birth weight < or = 2500 g had 20 year survival of 92% (89% to 95%), while those with birth weight > 2500 g had survival of 87% (84% to 89%). Subjects with gestational age of > 37 weeks had 20 year survival of 93% (91% to 96%), while those with gestational age > or = 37 weeks had survival of 85% (83% to 88%). Birth weight and gestational age were less predictive of survival than functional disability. Best statistical model used gestational age and number of severe functional disabilities as predictors. CONCLUSIONS--Life expectancy of this cohort of children with cerebral palsy was greater than has been suggested in some previous studies. This has important implications for social, educational, and health services.     

Variation of hamstrings lengths and velocities with walking speed

Crouch gait, one of the most prevalent movement abnormalities among children with cerebral palsy, is frequently treated with surgical lengthening of the hamstrings. To assist in surgical planning many clinical centers use musculoskeletal modeling to help determine if a patient’s hamstrings are shorter or lengthen more slowly than during unimpaired gait. However, some subjects with crouch gait walk slowly, and gait speed may affect peak hamstring lengths and lengthening velocities. The purpose of this study was to evaluate the effects of walking speed on hamstrings lengths and velocities in a group of unimpaired subjects over a large range of speeds and to determine if evaluating subjects with crouch gait using speed matched controls alters subjects’ characterization as having “short” or “slow” hamstrings. We examined 39 unimpaired subjects who walked at five different speeds. These subjects served as speed-matched controls for comparison to 74 subjects with cerebral palsy who walked in crouch gait. Our analysis revealed that peak hamstrings length and peak lengthening velocity in unimpaired subjects increased significantly with increasing walking speed. Fewer subjects with cerebral palsy were categorized as having hamstrings that were “short” (31/74) or “slow” (38/74) using a speed-matched control protocol compared to a non-speed-matched protocol (35/74 “short”, 47/74 “slow”). Evaluation of patients with cerebral palsy using speed-matched controls alters and may improve selection of patients for hamstrings lengthening procedures.