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Prof. Dr. med. Dr. phil. Heide Elke Viehweger

Department of Clinical Research
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Projects & Collaborations

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Dynamic foot function in patients with Charcot Marie Tooth disease

Research Project  | 5 Project Members

Charcot-Marie-Tooth disease (CMT) stands as one of the most prevalent hereditary neurological disorders, also recognized as hereditary motor and sensory neuropathy (HMSN) [1]. It ranks as the most common inherited neuropathy. CMT displays genetic diversity, involving over 80 mutated genes with varying inheritance patterns [2]

The majority of CMT cases fall into the CMT1 group, characterized by a demyelinating pattern of nerve damage. Within this group, CMT1A comprises 70% of all CMT patients and is linked with a defect on chromosome 17 that affects the peripheral myelin protein. Conversely, CMT2 cases exhibit an axonal pattern of nerve damage [3]

Individuals with CMT typically experience progressive muscle atrophy and weakness, leading to foot deformities and less frequently, hand deformities. The progression of deformities varies based on genetic and phenotypic factors. The disease often manifests as a multiplanar foot deformity, with cavovarus being the most observed. This deformity entails hindfoot varus, a high arch (cavus), downward flexion of the first metatarsal, a forefoot that's pulled inward (adducted), and claw toes. It arises from an imbalance in muscle strength, where the peroneus longus muscle may be relatively strong compared to a weakened anterior tibial muscle, or where the posterior tibial muscle is strong while the peroneus brevis muscle is weak [4, 5]

Patients with cavovarus deformity experience varying degrees of sensory loss, muscle weakness, painful foot calluses, abnormal gait, and ankle instability [3-6]. Despite ongoing research, the full understanding of these deformities remains elusive, leading to a variety of treatment recommendations. Therefore, the aim of this project is, to investigate and characterize functional gait parameters in CMT patients to improve therapeutic management. 

To develop a sufficient therapeutic program (such as foot surgery and orthotics management), biomechanical knowledge on 1) the deviations from healthy function and 2) how the foot deformities influence dynamic function, are necessary.

1. Lisak RP., D.D.T., WILLIAM M. CARROLL, ROONGROJ BHIDAYASIRI, International Neurology – A Clinical Approach, ed. D.D.T. Lisak RP., WILLIAM M. CARROLL, ROONGROJ BHIDAYASIRI. 2009: Blackwell Publishing Ltd. 

2. Timmerman, V., A.V. Strickland, and S. Zuchner, Genetics of Charcot-Marie-Tooth (CMT) Disease within the Frame of the Human Genome Project Success. Genes (Basel), 2014. 5(1): p. 13-32. 

3. Newman, C.J., et al., The characteristics of gait in Charcot-Marie-Tooth disease types I and II. Gait Posture, 2007. 26(1): p. 120-7. 

4. Mann, R.A. and J. Missirian, Pathophysiology of Charcot-Marie-Tooth disease. Clin Orthop Relat Res, 1988(234): p. 221-8. 

5. Beals, T.C. and F. Nickisch, Charcot-Marie-Tooth disease and the cavovarus foot. Foot Ankle Clin, 2008. 13(2): p. 259-74, vi-vii. 



BASEC-ID: 2024-00652

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Patient-specific musculoskeletal models to predict surgical outcome

Research Project  | 3 Project Members

Instrumented clinical gait analysis is used routinely to inform decision-making in neuro-orthopaedics. In addition to gait analysis, musculoskeletal modeling may become a powerful and non-invasive tool to guide clinical management and predict treatment outcomes. However, musculoskeletal modeling needs to integrate patient-specific adaptations, and its outputs need to be validated on a larger scale before it may be used in standard clinical practice.

The goal of this project is to develop patient-specific gait simulations by means of an open-source musculoskeletal modeling software. Results will be validated against existing clinical data pre vs post a typical intervention in neuro-orthopaedics.

Personalized musculoskeletal models from 30 children who received botulinum toxin injection will be developed from gait analysis data obtained before the intervention. To predict patient's response, the botulinum toxin effect will be simulated by weakening the model muscle and running a forward dynamic simulation. I will compare the outcome against existent data post-injection and analyze how induced muscle weakness alters the gait of children with cerebral palsy, providing validation for this specific musculoskeletal modeling application and overall confidence in our framework reliability.


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Getting high level of evidence for surgical treatments from routine clinical data. A real-world testing of the SPHN infrastructure - EVIGAITCP

Research Networks (Institutional Membership)  | 4 Project Members

Cerebral palsy is the first cause of disability with a prevalence of about 2.5 in 1000 children born in developed countries, that is about 250 children every year in Switzerland. The primary cause of cerebral palsy is a brain lesion occurring shortly before or after birth. The brain lesion is static and does not progress with time but secondary consequences, such as joint contractures and bony deformities develop during childhood and adolescence. A variety of surgical interventions and orthotics prescriptions may be performed to improve the biomechanical capacity of the musculoskeletal system once the deformities have developed.

However, ethical and practical difficulties to organise randomised controlled trials within the field of surgery have led to low or moderate level of evidence to support the interventions. In addition, different patients may respond markedly differently to the same treatment. In this context, the principles of evidence-based medicine are difficult to apply by clinicians when choosing the most appropriate treatment for a given child, or when discussing their rationale with the families.

Since the 90s, instrumented gait analysis has been utilised to inform the clinical decision-making process, plan the details of surgical interventions when these are deemed necessary, and evaluate the outcome of these interventions. Instrumented gait analysis provides quantitative and objective measures of the walking function. It generates a rich dataset composed of more than 50 scalar values describing the lower limb anatomy and functioning as well as more than 80 waveforms describing the walking pattern of the patients.


In this project, routine clinical data collected in two leading gait analysis centres at the UKBB (Basel) and at the HUG (Geneva) will be connected to the SPHN infrastructure. The objectives of the project are to ensure the SPHN | Swiss Personalized Health Network 2 | 4 interoperability of gait analysis data collected in different clinical centres in Switzerland and internationally, to determine the causal treatment effect of some of the most common orthopaedic treatments to improve walking in children with cerebral palsy, and to quantify the added value of multicentric observational datasets.

This project aims to lay the foundation for national, and international, gait analysis data interoperability as well as support evidence-based clinical decision-making in the field of neuro-orthopaedics for children with cerebral palsy. 

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CADENCE - Clinical Biomechanics and Ergonomics Engineering Equipment

Research Project  | 5 Project Members

In December 2021, the new research unit ‘Clinical Biomechanics and Ergonomics Engineering’ (CADENCE) was formed at Department of Biomedical Engineering (DBE) at the University of Basel (https://dbe.unibas.ch/en/research/biomechanics-and-biomaterials/cadence/) comprising the research groups ‘Functional Biomechanics’, ‘Robot-assisted Theragnostics’, ‘Paediatric Orthopaedic Biomechanics and Musculoskeletal Modelling’, and ‘Spine Biomechanics’. CADENCE facilitates innovative and groundbreaking interdisciplinary research in biomedical engineering and biomechanics and serves as teaching facility for courses on diagnostic and therapeutic technologies within the new Master of Science program and the PhD programs at the DBE. The R`Equip grant supports CADENCE in the purchase of a range of state-of-the-art sensor technologies and the world’s first 3D gait rehabilitation robot ‘The FLOAT’. This investment is critical for the unique and internationally leading role of the research groups in the research and innovation ecosystem in the Basel region.

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Stop tip-toeing around toe-walking: towards a better understanding and more effective treatment of toe-walkers with cerebral palsy

Research Project  | 8 Project Members

Background and Rationale: Walking is the most common and necessary form of movement for humans, as it ensures active participation in activities of daily life. In the initial stages of learning to walk, gait is rather unstable as well as variable. During this initial phase, children need to successfully perform the entire gait cycle that involves touch-down (characteristic heel-strike where the ankle is flexed), lift-off and swing phases. The characteristic heel-strike is critical to walking both effectively (stable) and efficiently (energy). Children that suffer from neuro-developmental disorders (e.g. cerebral palsy, CP) are often not able to heel-strike, they tend to keep walking with a forefoot or flatfoot pattern (i.e. toe-walking). Children that toe-walk often show poorer levels of static and dynamic stability, leading to a lower quality of life compared to typically developing children (TD). Current research suggests multifactorial adaptations in central and/or peripheral nervous as well as the musculoskeletal system contribute to and result from toe-walking. Current treatment mainly focuses on physically restoring the capability to heel-strike, however, adherence to walking with heel-strike is poor. From clinical experience, we hypothesize psychological factors (primarily fear-of-falling) as well as inadequate reflex control might contribute to toe-walking behavior. Currently, the interplay between the nervous-, musculoskeletal-, and psychological systems and their impact on resulting walking patterns are poorly understood. In order to sustain effective gait by means of effective interventions, it is therefore critical to understand the interplay among the mechanisms that underpin toe-walking adaptation. Overall Objectives & Specific Aims: The purpose of this study is to explore the interplay among nervous-, musculoskeletal-, and psychological systems and how they impact toe-walking behavior, and vice versa. Here, we will determine the effect of psychological factors (via the use of a custom-designed virtual reality environment) on static vs. dynamic stability, motor control and coordination (indirect assessment of central nervous system function), as well as reflex control (Hoffmann-reflex, H-reflex, performance of peripheral nervous system). In addition, we will also investigate the effect of restoring heel striking in toe-walkers based on the indices as mentioned above. Expected Results: It is expected that toe-walkers will show poorer stability during standing and walking, have a reduced H-reflex amplitude, reduced number of muscle synergies as well as increased fear-of-falling compared to TD. With the use of a custom-made virtual reality (VR) environment, the fear-of-falling in children will be increased. VR induced fear-of-falling will lead to poorer stability during standing and walking tasks in TD; in toe-walkers such reactions are present already without VR but worsen during VR conditions. By restoring (via the use of orthoses) heel-strike in toe-walkers stability during standing and walking tasks will be improved, number of muscle synergies will be increased, fear-of-falling will be reduced, and performance on VR induced fear-of-falling will be improved. Impact: Although development of heel-strike behavior takes place early in life, not all children demonstrate this feature during walking in daily life. Lack of heel-strike behavior is less efficient and leads to poorer quality of life. Management strategies to restore this critical feature of walking, have failed primarily due to the fact that although the capability might be restored, the adherence to walking with heel-strike is poor. By focusing on understanding the interplay between nervous-, musculoskeletal-, and psychological factors that might predispose individuals to toe-walking, we will provide solutions to design effective treatment strategies in the future.

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Early Tenotomy prevents risk of Hip Dislocation in Patients with Cerebral Palsy: a medium-term Outcome

Research Project  | 4 Project Members

Cerebral palsy (CP) is a term addressing a group of disorders mostly affecting muscle tone, movement, and motor skills. It is caused by damage in the developing fetal or the child’s immature brain and leads to non-progressive spasticity, ataxia, or involuntary movements. CP is the most common pediatric disease and the leading cause of disability in children. The type of CP originates from the areas of the brain affected by the lesion.

Besides neurologic, gastrointestinal, respiratory, sleeping disorders, bone disease, oral health problems, impaired vision, hearing loss, genitourinary problems, drooling, or pain, orthopedic disorders are frequent complications associated with CP.


Regarding orthopaedic hip disorders in children with CP, hip subluxation is frequently seen, followed by hip luxation. The spasticity and muscle imbalance lead to an inward rotation, adduction, and flexion of the hip as well as a posterior pelvic tilt in CP patients. Consequently, it results in a migration of the femoral head that can lead to a subluxation of the hip. The severity of the hip subluxation correlates with greater Gross Motor Function Classification System (GMFCS) levels. Spastic muscle imbalance and the lack of weight-bearing in higher GMFCS levels lead furthermore to progressive structural changes around the hip joint.


The planned study aims to address the importance of early intervention in the prevention of hip subluxation and dislocation in CP patients. The study is going to elaborate on the influence of psoas, adductor and hamstring tenotomies in the prevention of hip dislocation and as a medium-term outcome. Following the surgery, the CP patients will be under hip surveillance with clinical examinations and AP pelvis radiographs according to the care pathways recommended by the American Academy for Cerebral Palsy. The Reimers Index, popliteal angle, hip extension as well as abduction will be monitored and evaluated. It intends to outline the factors influencing treatment outcomes, and it is warranted to refine the treatment protocols. Moreover, it is aimed to improve the support of well-located, pain-free hips, the prevention of hip dislocation and eventual bone operation and thus enhance the quality of life in children with CP. 


BASEC-ID: 2023-02374

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Motion analysis in the context of toe walking: are there criteria to differentiate idiopathic toe walkers?

Research Project  | 5 Project Members

Toe walking after the age of three years is considered abnormal. It is termed idiopathic toe walking (ITW) in the absence of a neurological or orthopedic condition. Children with ITW present with reduced ankle mobility, impaired balance, sensory issues, difficulties in motor control, and increased fall risk. There is a need to diagnose ITW in a holistic manner and improve the monitoring of interventions. The aim of our project is to get a better understanding on how ITW may affect dynamic stability to tackle these issues.

We explore if dynamic stability is altered during walking in children with ITW compared to typically developing (TD) peers and if there exists the possibility to identify dynamic biomarkers based to support diagnostics and therapeutic management


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