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Prevalence of specific gait abnormalities in children with cerebral palsy revisited: Influence of age, prior surgery, and Gross Motor Function Classification System level
Developmental Medicine & Child Neurology
Abstract
Aim:
To examine the impact of age, surgery, and Gross Motor Function Classification System (GMFCS) level on the prevalence of gait problems in children with cerebral palsy (CP).
Method:
Gait analysis records were retrospectively reviewed for ambulatory patients with CP. Gait abnormalities were identified using physical exam and kinematic data. Relationships among age, sex, previous surgery, GMFCS level, and prevalence of gait abnormalities associated with crouch and out-toeing, and equinus and in-toeing were assessed using univariable and multivariable logistic regression.
Results:
One-thousand and five records were reviewed. The most common gait problems were in-toeing, excessive knee flexion, stiff knee, hip flexion, internal rotation, adduction, and equinus (all >50%). Odds ratios (OR) for various gait problems associated with crouch and out-toeing increased (OR 1.07-1.32), and those associated with equinus and in-toeing decreased (OR 0.80-0.94) significantly with increasing age for patients in GMFCS levels I to III. The same trends were seen with prior surgery (OR for crouch and out-toeing: 1.86-7.14; OR for equinus and in-toeing: 0.16-0.59).
Interpretation:
The prevalence of gait abnormalities varies by GMFCS level, but similarities exist among levels. The study results suggest that in younger children, particularly those in GMFCS levels III and IV, treatments for equinus and in-toeing should be undertaken with caution because these problems tend to decrease with age even without orthopedic intervention. Such children may end up with the 'opposite' deformities of calcaneal crouch and out-toeing, which tend to increase in prevalence with age.
... Foot deformities such as valgus or varus in the coronal plane and equinus in the sagittal plane are common in children with cerebral palsy (CP) [1][2][3][4][5][6]. Their definitions vary in the literature, mainly describing the position of the hindfoot in valgus or varus, the reduced dorsiflexion of the ankle in equinus, commonly combined and/ or in association with forefoot deviations [1][2][3]7]. ...
... The development of foot deformities is multifactorial and is due to muscle imbalance and spasticity during growth [1-3, 6, 8]. In ambulatory children, foot deformities may affect standing and gait and result in tripping and falling when walking [6,9]. Furthermore, foot deformities can cause pain, pressure, and difficulty wearing shoes in both ambulatory and nonambulatory children [1][2][3]. ...
... Surgery and conservative treatment, such as physical therapy, insoles, ankle-foot orthoses, and botulinum neurotoxin A (BoNT-A) injections, are frequently used to manage foot deformities in children with CP [1,2,6,[10][11][12][13][14]. Foot and ankle surgeries stand out as the most prevalent surgical procedures in ambulatory children where 30% of all children with CP are likely to have foot and ankle surgery before the age of 15 years [11]. ...
Background
Foot deformities, such as valgus and varus in the coronal plane and equinus in the sagittal plane, are common in children with cerebral palsy (CP). The purpose of this study was to describe the prevalence of coronal plane foot deformities and their association with the Gross Motor Function Classification System (GMFCS) level, age, CP subtype, and equinus in children with CP.
Methods
A cross-sectional study was performed of 2784 children (1644 boys, 1140 girls), mean age 10 years, 2 months (standard deviation, 4.83), from the Swedish CP Follow-up Program and registry for 2021–2023. Single and multiple binary regression analyses estimated the association between coronal plane foot deformities (valgus or varus) and sex, age, GMFCS level, CP subtype, and equinus.
Results
More than half (58%) the children with CP had valgus feet and 6% had varus feet. Valgus feet were more common in young children with high GMFCS levels, whereas the number of varus feet remained consistently low across all GMFCS levels. The prevalence of valgus feet was lower in older children at GMFCS I and II, but remained high in older children at GMFCS III–V. Coronal plane foot deformities were associated with higher GMFCS levels (odds ratio [OR] 11, 95% confidence interval [CI] 8–15 for GMFCS V), lower age (OR 1.5, 95% CI 1.3–1.7), and equinus (OR 1.9, 95% CI 1.4–2.5).
Conclusions
Most children with CP have a coronal plane foot deformity. Valgus is most commonly associated with higher GMFCS levels and lower age. These findings contribute to a mapping of the children with an increased risk of foot deformities and also highlight the need for continuous follow-up of foot deformities in children with CP.
... In addition to the natural development of this gait pattern, there is an iatrogenic crouch gait pattern which is formed after unjustified fibromyotomies and isolated lengthening of the Achilles tendon performed at an early age. Moreover, an asymmetry in the severity of this type of movement disorders may develop between the limbs even in one person [5][6][7][8][9]. The subsequent inevitable weakening of the triceps of the lower leg leads to a loss of function of the soleus muscle and pathological (initially adaptive) flexion of the knee joint in the support phase. ...
... The locomotor profile was assessed by video computed gait analysis (CGA) in inpatient conditions in 27 children (54 limbs) with spastic diplegia, who had previously undergone fibromyotomies according to the Ulzibat method, open lengthening of the Achilles tendon. The mean age at the time of the survey was 13.0 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17) years. The control group consisted of 19 children without orthopedic pathology (38 limbs) of similar age. ...
... The analysis of the evaluation of gait patterns (compensated, decompensated and stiff-knee associated crouch gait patterns) revealed quantitative criteria of kinematics and kinetics in differentiating these patterns according to the parameters presented in Table 4. [8,19,20]. ...
The pattern of pathological crouch gait in patients with spastic paralysis is characteristic of diplegic forms and in natural development manifests itself
usually after the age of 10-12 years. This pathological gait may develop earlier after early surgical interventions that weaken the triceps of the lower
leg, especially the soleus muscle. The heterogeneity of the crouch gait pattern is diverse. Qualitative assessment of the difference in the decompensated
crouch pattern, especially associated with stiff-knee gait, according to the graphs of kinematics and kinetics of the joints can be difficult, and quantitative
criteria for differentiation have not been reflected in the literature. The purpose of the study was to conduct a comparative analysis of the quantitative
parameters of the compensated, decompensated and associated stiff-knee gait crouch pattern. Materials and methods The assessment of the locomotor
profile by 3D gait analysis (3DGA) was carried out in stationary conditions in 27 children (54 limbs) with spastic diplegia, who had previously undergone
percutaneous fibromyotomy according to the Ulzibat method, or open lengthening of the Achilles tendon. The mean age at the time of the survey was 13.0
(8–17) years. Control group: 19 children without orthopedic pathology (38 limbs) of the same age. Three groups of changes within the crouch gait pattern,
recorded on separate limbs, were distinguished: I – model of the crouch pattern of the “compensated” type (n = 30); II – model of the crouch pattern of
the "decompensated" type (n = 14); III – models of crouch pattern of the "stiff-knee" type (n = 10). Results An analysis of the evaluation of the models of
compensated, decompensated, and stiff-knee patterns of crouch gait revealed criteria for their differentiation in terms of quantitative indicators of kinematics
and kinetics. GPS: compensated and decompensated crouch gait up to 25.0, stiff-knee gait – more than 25.0. The angle of maximum dorsiflexion of the foot
in the stance phase: compensated and decompensated crouch pattern up to 35.0°, stiff-knee crouch pattern – more than 35.0°. Knee joint extension range:
compensated crouch over 11.0°, stiff-knee gait up to 6.0°. Flexion knee joint range: compensated crouch more than 11.0°, stiff-knee gait – up to 6.0°. The
strength of the leg extensor muscles during the formation of the support push: compensated and decompensated crouch less than 1.0 H*m/kg, stiff-knee –
more than 1.0 N*m/kg. The strength of the leg flexor muscles in the midstance period: compensated crouch less than 0.25 H*m/kg, stiff-knee – more than
0.75 N*m/kg. Absorption power (negative) of the knee joint: compensated and decompensated crouch more than 0.9 W/kg, stiff-knee less than -0.9 W/kg.
Useful peak power of the joints: compensated and decompensated crouch patterns – more than 0.40 W/kg, stiff‑knee gait – less than 0.40 W/kg. Conclusions
The development of the crouch gait pattern in the absence of a tertiary compensatory deviation (torso tilt) can be formed with or without a decrease in the
power of the joints. The decompensated and compensated types of the crouch pattern have a significant difference in the kinematics of the knee joint and in
the duration of the internal moment of extension, while the power parameters of the joints do not have significant differences. Stiff-knee associated crouch
pattern is the most severe type in which all the power parameters of the joints are decreased. The manifestation of the severity of this pathological pattern
may vary between the right and left limbs of the individual.
... However, a subsequent prospective analysis of stance phase knee flexion indicated that 56% of a cohort of 48 showed improvement in knee flexion between baseline and final assessment [11]. Although they included those who underwent surgical intervention, Rethlefsen et al. [12] found a tendency for individuals with CP to show increasing crouch and outtoeing and reducing intoeing and equinus with age in a cohort of 1005. ...
... Kinematic time series data (whole stride) were extracted for baseline and final available analyses. The GDI score was calculated through comparison with a local dataset of typical developing individuals (n = 33; age [5][6][7][8][9][10][11][12][13][14]. Walking speed, step and stride length were normalised for subject height. ...
... Marron et al. [6] reported increasing external knee rotation in a non-surgical control group. Rethlefsen et al. [12] also indicated an age-related progression to more external foot progression in a large cohort including those with a surgical history. The results of this study confirmed this age-related change over time. ...
... The most common musculoskeletal deformity in ambulant children with cerebral palsy (CP) is equinus, defined as a fixed contracture of the gastrocnemius or gastrocnemius and soleus muscles [1]. Equinus gait can cause tripping, falling, and may ultimately impact participation [1,2]. Children with hemiplegia may present with unilateral equinus on their affected side [3]. ...
... Children with hemiplegia may present with unilateral equinus on their affected side [3]. Children with diplegia may present with unilateral or bilateral equinus, and bilateral equinus may be symmetrical or asymmetrical [1,2,4]. Management of fixed equinus is treated by surgical lengthening of the gastrocsoleus muscle-tendon unit (MTU), by a variety of techniques [5]. ...
Background:
Gastrocsoleus lengthening (GSL) is the most common surgical procedure to treat equinus deformity in ambulant children with cerebral palsy (CP). Foot drop, where the ankle remains in plantarflexion during swing phase, can persist in some children post-operatively. There is currently limited understanding of which children will demonstrate persistent foot drop after GSL.
Research question:
Which children develop persistent foot drop after GSL surgery for equinus?
Methods:
We conducted a retrospective cohort study on ambulant children with CP who had GSL surgery for fixed equinus deformity. The aims of the study were: to determine the frequency of persistent foot drop post-operatively and to compare outcome parameters from physical examination and three-dimensional gait analysis for children with hemiplegia or diplegia.
Results:
One hundred and ten children functioning at GMFCS Levels I/II/III of 28/75/7 met the inclusion criteria for this study. There were 71 boys and mean age was 9.1 years at time of GSL surgery. The overall frequency of persistent foot drop was 25%, with a higher frequency of persistent foot drop in children with hemiplegia (42%) than children with diplegia (19%). There were significant improvements in dorsiflexor strength and in selective motor control in children with diplegia but not in children with hemiplegia. Mean (SD) pre-operative mid-swing ankle dorsiflexion for children with hemiplegia was - 14.0° (9.9°) and improved post-operatively to - 1.6° (5.5°). For children with diplegia, the pre-operative mid-swing ankle dorsiflexion was - 12.1° (12.9°) and improved post-operatively to + 4.2° (6.9°).
Significance:
Foot drop is present following GSL surgery for fixed equinus deformity in a significant number of children with hemiplegia and to a lesser extent in children with diplegia, which may reflect a difference in the central nervous system lesion between these groups. New management approaches are required for this important and unsolved problem.
... There has been a significant amount of work done in the application of wearable sensors to provide more effective treatment and diagnostics in healthcare setting [14], [15]. However, within the field of analysing gait, the two areas that receive the most attention are that of Parkinsons' disease [16], [17], [18] and cerebral palsy [19], [20], [7]. ...
... 29 of these were applied to the analysis of gait. Until recently, machine learning is infrequently used in the analysis of gait compare to more traditional measures [19], [20], [7], [2]. However, more recently the use of machine learning to analysie gait in combinations of settings and with various modalities has become increasingly popular [21], [25], [26], [22], [23], [24]. ...
In this work we investigate the effectiveness of a wireless in-shoe pressure sensing system used in combination with a type of machine learning referred to as long term short term memory networks (LSTMs) to classify multiple interacting gait perturbations. Artificially induced gait perturbations consisted of restricted knee extension and altered under foot centre of pressure (COP). The primary aim was to assess the capacity to diagnose gait abnormalities without the need to attend a gait laboratory or visit a clinical healthcare professional, through the use of technology. Ultimately, such a system could be used to autonomously generate therapeutic guidance and provide healthcare professionals with accurate up to date information about a patients gait. The results show that LSTMs are capable of classifying complex interacting gait perturbations using in-shoe pressure data. When testing, 11 of 12 perturbation conditions were correctly classified overall and 58.8% of all data instances were correctly classified (8.3% is random classification). This work illustrates that an automated low cost, non-invasive gait diagnosis system with minimal sensors can be used to identify interacting gait abnormalities in individuals and has further potential to be used in a healthcare setting.
... E quinus gait, characterized by excessive ankle plantarflexion in the stance and swing phases of gait, is a common gait disruption pattern seen in children with cerebral palsy (CP). 1,2 The 2 most common causes of equinus gait are dynamic overactivity or fixed shortening (myostatic deformity) of the gastrocsoleus complex (GSC). Myostatic deformity of the GSC causing gait disruption in children with CP is typically managed by surgical lengthening of the GSC muscle-tendon unit (MTU). ...
... 7 Ankle equinus (defined as increased ankle plantarflexion during stance and swing phases of the gait cycle) is the most common gait deviation seen in children with CP who are ambulatory, and correction of dynamic /myostatic deformity of the GSC by lengthening is the most common surgery performed to improve gait in these children. [1][2][3][4]25 It is recognized that there are multiple variables that determine the gait outcomes following surgical lengthening of the GSC. It has been postulated that insufficient lengthening can result in the persistence or recurrence of the equinus gait deviation over time in the growing child. ...
Background: Tendo Achilles lengthening (TAL) for the management of equinus contractures in ambulatory children with cerebral palsy (CP) is generally not recommended due to concerns of overlengthening, resulting in weakness and plantar flexor insufficiency. However, in some cases, surgical correction of severe equinus deformities can only be achieved by TAL. The goal of this study is
to assess the outcomes following TAL in these cases.
Methods: A retrospective cohort study of children with CP with severe equinus contractures (ankle dorsiflexion with the knee extended of -20 degrees or worse) who underwent TAL as part of a single event multilevel surgery, with preoperative and postoperative gait analysis studies. Continuous data were analyzed by paired t test, and categorical data by McNemar Test.
Results: There were 60 subjects: 42 unilateral, 18 bilateral CP; 41 GMFCS II, 17 GMFCS I; mean age at surgery was 10.6 years, mean follow-up was 1.3 years. Ankle dorsiflexion with the knee extended improved from −28 to 5 degrees (P<0.001). The ankle Gait Variable Score improved from 34.4 to 8.6 (P<0.001). The ankle moment in terminal stance improved from 0.43 to 0.97 Nm/kg (P< 0.001). Significant improvements (P<0.001) were seen in radiographic measures of foot alignment following surgery. There were few significant differences in the outcome parameters between subjects with unilateral versus bilateral CP (eg, only the bilateral group showed improved but persistent increased knee flexion in mid-stance).
Conclusions: The outcomes following TAL for the management of severe equinus deformity in ambulatory children with CP were favorable 1 year after surgery, with significant improvements in all domains measured.
Significance: This study does not advocate for the widespread use of TAL to correct equinus deformity in children with CP. However, it does show that good short-term outcomes following TAL are possible in properly selected subjects with severe contractures when the dosing of the surgery is optimal (correction of contracture to between 0 and 5 degrees of dorsiflexion with the knee extended) and the procedure is performed in the setting of single event multilevel surgery with subsequent proper orthotic management and rehabilitation.
... In ambulatory children with cerebral palsy (CP), crouch gait is the most common gait pathology in older children. 1 A recent systematic review reported that the natural history of crouch gait was for increasing knee flexion in children with spastic diplegia, over time. 2 A large population-based study found that knee flexion deformity may significantly impair functional mobility, as measured using the Functional Mobility Scale (FMS). 3 The causes of crouch gait are complex and multi factorial. ...
... 2,3,8 Children who lack knee extension during the stance phase of gait are usually described as having flexed knee gait or crouch gait. [1][2][3][4][5][6]8,9 Some reserve the term crouch gait for a gait pattern in which there is incomplete exten sion/excessive flexion at the hip and knee, combined with calcaneus at the ankle. 9 Crouch is a subset of flexed knee gait, and it may be important to recognize it as a distinct entity in a classification system because the etiol ogy, natural history, urgency to treat, treatment options, and outcomes may differ from other types of flexed knee patterns. ...
Purpose
In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement.
Method
A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022.
Results
There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates.
Conclusion
The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research.
Level of evidence
level V.
... This was a consequence of a decrease in the load on the heel, f_h by 36% (see Table 4 and Fig. 2 a) and its increase in the load on the toe, f_t by 29% (see Table 4, Fig. 2 b). Our results do not contradict the data of the world literature, according to which the equinus deformity of the feet in the children with CP is the most common [17,18,19,20]. The parents often describe this condition as "walking on the toes." ...
... For the rest of the indicators, there was no such pronounced tendency to change as the patient's gross motor functions impairment increased. Our results are consistent with the literature data, according to which, with the aggravation of movement disorders, there is an increase in the number of deformities from the musculoskeletal system [20,28,29,30] and, as a consequence, an impairment of the interzonal distribution of the load on the plantar surface of the foot. ...
Relevance. The main direction of rehabilitation of children with cerebral palsy is the preservation and enhancement of the existing level of support and locomotion, as well as compensation of its impairment through various methods of rehabilitation. For an adequate prescription and reliable assessment of these measures effectiveness, it is necessary to use objective indicators of functional impairment characteristic of cerebral palsy. The purpose of this study was to substantiate objective biomechanical indicators of functional impairment in children with cerebral palsy based on the analysis of the interzonal distribution of the load on the foot during walking, taking into account the level of global motor functions impairment. Materials and Methods. 47 children with cerebral palsy at the GMFCS levels of impairment 1 to 3 were examined. The control group consisted of 14 children without anatomical and functional signs of support and locomotion system impairment. Biomechanical examination was performed on the complex «DiaSled-M-Scan» with matrix plantar pressure meters in the form of insoles. The statistical analysis of the data was carried out by nonparametric methods using the SPSS for Widows software. Results. The analysis of the anatomical and functional impairment of 94 feet of the children with cerebral palsy and 28 feet of the control group revealed differences in the interzonal distribution of the load under the feet in six variables (p from 0.001 to 0.003). The most typical were: an increase in the toe-to-heel load ratio (on average by 80%), an increase in the load on the arch (by 49%), and a decrease in the medio-lateral load ratio on the toe (by 37%). For GMFCS 1 patients, a significant indicator of impairment was an increase in the partial load on the arch, for GMFCS 2 and 3 patients — a decrease in the load on the heel and an increase it under the toe. This leads to an increase in the toe-to-heel load ratio. Conclusion. It is advisable to use the revealed indicators of roll-over-the-foot impairment in the functional diagnosis of the condition and in assessing the effectiveness of rehabilitation of children with cerebral palsy.
... There are only a few reports specifically characterizing gait patterns in patients with unilateral CP [5][6][7][8]. The underlying movement pathology, which may cause a chain of further tertiary movement abnormalities, can hardly be detected visually with sufficient validity [9]. ...
... So far, six multiple joint patterns for CP have reached scientific consensus ("drop foot", "true equinus", "apparent equinus", "genu recurvatum", "jump gait", and "crouch gait" [11]) all of which represent sagittal plane deviations. However, transversal plane deviations have been described in the past, yet not considered for classification sufficiently [2,7,11,20]. ...
Classification of gait disorders in cerebral palsy (CP) remains challenging. The Winters, Gage, and Hicks (WGH) is a commonly used classification system for unilateral CP regarding the gait patterns (lower limb kinematics) solely in the sagittal plane. Due to the high number of unclassified patients, this classification system might fail to depict all gait disorders accurately. As the information on trunk/pelvic movements, frontal and transverse planes, and kinetics are disregarded in WGH, 3D instrumented gait analysis (IGA) for further characterization is necessary. The objective of this study was a detailed analysis of patients with unilateral CP using IGA taking all planes/degrees of freedom into account including pelvic and trunk movements. A total of 89 individuals with unilateral CP matched the inclusion criteria and were classified by WGH. Subtype-specific differences were analyzed. The most remarkable findings, in addition to the established WGH subtype-specific deviations, were pelvic obliquity and pelvic retraction in all WGH types. Furthermore, the unclassified individuals showed altered hip rotation moments and pelvic retraction almost throughout the whole gait cycle. Transversal malalignment and proximal involvement are relevant in all individuals with unilateral CP. Further studies should focus on WGH type-specific rotational malalignment assessment (static vs. dynamic, femoral vs. tibial) including therapeutic effects and potential subtype-specific compensation mechanisms and/or tertiary deviations of the sound limb.
... Additionally, applying this technique to treat neuropathic midfoot ulcers without total contact casting resulted in a 91% healing rate [49], further highlighting its efficacy in complex diabetic foot conditions. The most common of the musculoskeletal deformities in ambulant children with CP is equinus, caused mainly by gastrocnemius spasm, or contracture, which can be managed through a gastrocnemius-soleus recession [45,[51][52][53][54]. Such an intervention can be conducted as a standalone procedure or be integrated into multi-level surgery that addresses additional musculoskeletal deformities [55][56][57][58]. ...
This paper aims to review the various surgical techniques for gastrocnemius–soleus recession and Achilles tendon lengthening, with a special focus on the treatment of clubfoot and cerebral palsy (CP) equinus contracture. This descriptive review article comprehensively explores different techniques for gastrocnemius recession, including the Hoke percutaneous triple hemisection, Baker’s method (Tongue-in-Groove Gastrocnemius–Soleus Recession), the Vulpius method, the Baumann procedure, and the Strayer procedure (Gastrocnemius Recession). The objective is to present a detailed analysis of these methods, covering their indications, procedural nuances, relevance in clinical practice, and outcomes.
... he skeletal-muscular system of the human body is an interconnected set and changes in any part of it can affect other parts and cause problems in basic motor skills, such as walking [1,2]. Walking activity is one of the main tasks of the lower body, by performing various actions, such as absorbing, the forces resulting from the impact of the foot on the ground, maintaining balance, and producing forward forces, plays an essential role in creating an integrated and properly coordinated pattern of walking [2][3][4]. A previous study has shown that natural walking requires neurally controlled commands, force generation by the muscles, and a specific range of motion for each case. ...
... An equinus pattern has a prevalence of ;49%. 4 Spastic CP is the most common subgroup of CP and is characterized by abnormal posture or movement patterns; increased muscle tone; and pathological reflexes such as hyperreflexia or pyramidal signs, for example, the Babinski reflex. 5 Furthermore, it can be divided into unilateral spastic CP (USCP), in which extremities on only 1 side of the body are affected, and bilateral spastic CP, in which extremities on both sides of the body are affected. ...
Background
In children with unilateral spastic cerebral palsy (USCP), ankle-foot orthoses (AFOs) are widely used to correct common gait deviations such as a drop-foot pattern. Most studies on this topic have investigated specific time points while omitting other parts of the gait cycle.
Objectives
This study investigated the separate effects of prefabricated carbon fiber AFOs and custom-made hinged AFOs compared with barefoot walking in children with USCP with a drop-foot gait pattern using statistical parametric mapping.
Study design
Retrospective, cross-sectional, repeated measures study.
Methods
Twenty ambulatory children (9.9 ± 2.5 years) with USCP and a drop-foot gait pattern were included. Kinematics, kinetics, and spatiotemporal parameters assessed during 3-dimensional gait analysis were compared between barefoot and AFO walking. Statistical parametric mapping was used to compare joint angles and moment waveforms. Kinematics, kinetics and spatiotemporal parameters assessed during 3-dimensional gait analysis were compared between barefoot and AFO walking for each AFO type but not between the 2 AFO types.
Results
Compared with barefoot walking, there was a steeper sole angle at initial contact, corresponding to a heel strike pattern, and an increased ankle dorsiflexion in swing with the use of both AFOs. The ankle plantar flexion moment during loading response increased. Ankle power generation during pre-swing decreased in the carbon fiber AFO group when walking with AFOs.
Conclusions
Both AFOs were beneficial for improving a drop-foot gait pattern in these small patient groups and can, therefore, be recommended to treat this gait deviation in patients with unilateral cerebral palsy. However, the reduction in ankle power generation during push-off and additional goals targeted by AFOs, such as correction of structural or flexible foot deformities, should be considered for prescription.
... Therefore, to execute a proper gait pattern, proper alignment of lower limb joint segments with proper positioning of foot and ankle are crucial requirements. [7] A wide variety of interventions, such as botulinum injections, [8] bracing, splinting, orthosis, [9] and orthopedic surgeries, [10] along with conventional physical therapy (CPT) interventions, are used to address these motor impairments. ...
ABSTRACT
Background
Cerebral palsy (CP) is a nonprogressive developmental disorder characterized by motor deficits, such as abnormal posture, balance, and gait impairments leading to deformities, affecting activities daily and, therefore, the quality of life. The application of Kinesio taping (KT) in patients with CP has emerged as a choice of adjunct treatment. Therefore the objective of this review was to evaluate the effectiveness of KT as an addition to conventional physiotherapy (CPT) interventions on posture, balance, and gait in spastic cerebral palsy.
Materials and Methods
A bibliographic search was done in various databases. Only randomized controlled trials on KT in CP were included. The risk of bias in included studies was evaluated by using the RoB 2.0 tool. Downs and Black checklist was used to determine the overall quality of studies.
Results
A total of five studies were eligible, out of which two studies reported a low risk of bias and three studies reported some concerns on RoB 2.0. The overall methodological quality of the studies ranged from fair to good. Out of five studies in three studies, KT was more effective as adjunct CPT than CPT alone on sitting posture, balance, and standing balance. In one study, KT was equally effective as ankle foot orthosis on gait. Lastly, one study showed a significant improvement with KT application over CPT alone, but the effects of neuromuscular electrical stimulation were more significant than KT on postural control and sitting.
Conclusion
KT is a noninvasive, inexpensive, and compliant adjunct to physiotherapy in patients with spastic CP for better outcomes regarding posture, balance, and gait.
... 2 This column indicates the number of limbs in which the maximum HMTL across all exercises ( HMTL * max ) was provoked in each exercise (number of limbs/ total number of included limbs). 3 This column indicate the number of limbs in which the observed HMTLmax exceeded the individual normative HMTLmax in each exercise (number of limbs/ total number of included limbs). ...
This study introduces a functional exercise protocol to improve the identification for short hamstring muscle–tendon length (HMTL), a common contributor to crouch gait in patients with central neurological lesions (CNL). The functional exercise protocol incorporates a knee extension movement with hip in a flexed position, while standing on one leg (functional popliteal angle test) and walking with large steps to the current standard protocol (walking at comfortable speed and as fast as possible). The main aim was to establish whether the new protocol allows better determination of maximum HMTLs and diagnostics of short HMTL in patients with a CNL. Lower limb 3D marker position data from 39 patient limbs and 10 healthy limbs performing the exercises were processed in OpenSim to extract HMTLs. The new protocol provoked significantly larger HMTLs compared to the current standard protocol. The total number of limbs classified as having too short HMTLs reduced from 16 to 4 out of a total of 30 limbs walking in crouch. The new protocol improves determination of maximum HMTL, thereby improving short HMTL diagnostics and identification of patients in need of lengthening treatment. Inter-individual variability observed among patients, indicating the need to include all exercises for comprehensive diagnosis.
... Within new treatment concepts developing over the last years, the focus has changed somewhat away from a priori managing spasticity toward addressing the two other muscular key features of BSCP -weakness and impaired selective motor control, as well. Given the high likelihood of developing a crouch gait pattern during trajectory, training of the lower limb extensors and hip abductors becomes important to prevent and counteract the development of biomechanical malalignments of the lower extremity and pelvis, decrease compensatory trunk lean and enhance balance as well as endurance in standing and walking (8)(9)(10)(11)(12)(13)(14)(15)(16). In addition to orthoses that support foot leverage as well as aids supporting standing and walking, conventional and instrumented physiotherapy (e.g., robotassisted treadmill training, whole body vibration training), are helpful approaches to improve power and endurance in children with BSCP (4). ...
Background
Impaired selective motor control, weakness and spasticity represent the key characteristics of motor disability in the context of bilateral spastic cerebral palsy. Independent walking ability is an important goal and training of the gluteal muscles can improve endurance and gait stability. Combining conventional physical excercises with a neuromodulatory, non-invasive technique like repetitive neuromuscular magnetic stimulation probably enhances effects of the treatment. This prospective study aimed to assess the clinical effects of repetitive neuromuscular magnetic stimulation in combination with a personalized functional physical training offered to children and adolescents with bilateral spastic cerebral palsy.
Methods
Eight participants Gross Motor Function Classification System level II and III (10.4 ± 2y5m; 50% Gross Motor Function Classification System level II) received a personalized intervention applying functional repetitive neuromuscular magnetic stimulation (12 sessions within 3 weeks; 12,600 total stimuli during each session). At baseline and follow up the following assessments were performed: 10-m-walking-test, 6-min-walking-test, GMFM-66. Six weeks after the end of treatment the patient-reported outcome measure Gait Outcome Assessment List was completed.
Results
GMFM-66 total score improved by 1.4% (p = 0.002), as did scoring in domain D for standing (1.9%, p = 0.109) and domain E for walking, jumping and running (2.6%, p = 0.021). Gait speed or distance walked during 6 min did not improve from baseline to follow up. Patient-reported outcome showed improvement in 4 patients in altogether 14 ratings. Caregiver-reported outcome reported benefits in 3 participants in altogether 10 ratings.
Conclusion
Repetitive neuromuscular magnetic stimulation promises to be a meaningful, non-invasive treatment approach for children and adolescents with bilateral spastic cerebral palsy that could be offered in a resource-efficient manner to a broad number of patients. To further investigate the promising effects of repetitive neuromuscular magnetic stimulation and its mechanisms of action, larger-scaled, controlled trials are needed as well as comprehensive neurophysiological investigations.
... In addition, muscle control abnormalities, femoral deformities, or pelvis instability in children with CP may contribute disrupting gait control when this requires a reorganization of muscle activity and specific sensorimotor adjustments following a change of direction of progression. Detailed descriptions of forward gait abnormalities in CP have been reported in numerous studies 26 . However, there is limited evidence on the mechanisms of this locomotor behavior in children with CP. ...
Switching locomotion direction is a common task in daily life, and it has been studied extensively in healthy people. Little is known, however, about the locomotor adjustments involved in changing locomotion direction from forward (FW) to sideways (SW) in children with cerebral palsy (CP). The importance of testing the ability of children with CP in this task lies in the assessment of flexible, adaptable adjustments of locomotion as a function of the environmental context. On the one hand, the ability of a child to cope with novel task requirements may provide prognostic cues as to the chances of modifying the gait adaptively. On the other hand, challenging the child with the novel task may represent a useful rehabilitation tool to improve the locomotor performance. SW is an asymmetrical locomotor task and requires a differential control of right and left limb muscles. Here, we report the results of a cross-sectional study comparing FW and SW in 27 children with CP (17 diplegic, 10 hemiplegic, 2–10 years) and 18 age-matched typically developing (TD) children. We analyzed gait kinematics, joint moments, EMG activity of 12 pairs of bilateral muscles, and muscle modules evaluated by factorization of EMG signals. Task performance in several children with CP differed drastically from that of TD children. Only 2/3 of children with CP met the primary outcome, i.e. they succeeded to step sideways, and they often demonstrated attempts to step forward. They tended to rotate their trunk FW, cross one leg over the other, flex the knee and hip. Moreover, in contrast to TD children, children with CP often exhibited similar motor modules for FW and SW. Overall, the results reflect developmental deficits in the control of gait, bilateral coordination and adjustment of basic motor modules in children with CP. We suggest that the sideways (along with the backward) style of locomotion represents a novel rehabilitation protocol that challenges the child to cope with novel contextual requirements.
... La marcha agachada, como una de las anormalidades que se estudian en este trabajo de investigación, es una de las anomalías más comunes y se observa en personas con parálisis cerebral [38], la cual se caracteriza por una flexión excesiva en cadera, rodilla y tobillo [27,87,119]. De igual manera, la marcha agachada también es característica en personas hemipléjicas después de un derrame [1]. ...
Gait recognition is a computational approach to the analysis of human gait. This
approach is based on the evaluation and comparison of each individual walking patterns. This work focuses on the development of a framework for the analysis and automatic recognition of gait abnormalities based on human kinematics. The first stage of the framework consists of the development of forward kinematic of position modeling of an 8 degrees of freedom (DoF) system and a reduced 3 DoF system that represent the lower limbs during the gait cycle. In this stage, the conventional methods based on geometry and Denavit-Hartenberg are used, and a novel approach for calculating the kinematics based on quaternion algebra is proposed. Derived from the above, the analysis and visualization of normal gait and crouch gait in Cartesian space in the 3 anatomical planes based on unconventional metrics is performed. In the second stage of the research work, a method based on geometry and coordinate transformation is proposed for the calculation of the inverse kinematics of position of the same kinematic models of 8 DoF and 3 DoF, respectively. In this phase, the analysis and visualization of the normal gait and crouched gait is conducted in the 3 anatomical planes in the joint space.
The last stage consists in the development of a framework for antalgic and non-antalgic gait recognition, based on an experimental system for the measurement of activity using the gyroscope of a smartphone. In this stage, a detailed description of each of the phases of the workflow is provided, emphasizing the experimental design, data validation, as well as features extraction/selection. The classification algorithms used are k-nearest neighbors, Naive Bayes, support vector machines, linear discriminant analysis, decision trees, and classifier ensemble. The metrics used to evaluate the performance of the classification stage are accuracy, f-measure, sensitivity, specificity, and precision.
... Impaired walking stereotype of patients with spastic cerebral palsy along with orthopaedic disorders, are associated with adduction alignment/contractures of the hip joints [1][2][3]. Invasive procedures are reported to be mainly used to correct the disorders [4][5][6][7]. There is a paucity of publications reporting the role of conservative treatments with the use of hip orthoses [8,9]. ...
Introduction Adduction or flexion-adduction contracture of the hip joint often causes static and dynamic impairments in children with spastic cerebral
palsy that can be corrected with hip abduction orthosis. No reports confirming or rejecting the effectiveness of the method in the gait correction
have not found. The objective was to explore the effect of the hip abduction orthosis on gait kinematics in children with spastic cerebral palsy.
Material and methods Twelve biomechanical tests were performed for 6 patients of GMFCS level 3 (6 tests with hip abduction orthosis and 6 tests
with no hip abduction orthosis). Gait analysis was produced using the Qualisys Miqus M5 motion capture system (Sweden). Clinical gait analysis was
performed with PAF 2.0 of QTM software, Visual3D, Statistica 10 and Excel. Results A comparative analysis of the mean values showed differences
in the gait parameters depending on test conditions. Improvements in the spatial-temporal parameters ranged between 0.4 % and 23.6 % with use of
orthosis. The kinematic analysis of large joints demonstrated a slight positive effect on the hip joint function. There were no significant differences in the
function of other joints. The use of orthosis improved the overall gait index score for the left and right lower limbs by 12.5 % and 5.7 %, respectively.
A detailed analysis of the gait index for large joints of the lower limbs demonstrated the discrete improvement. Conclusion Hip abduction orthosis
showed a positive effect on the gait pattern of children with spastic cerebral palsy.
... Crouch gait (CG) is one of the most common gait abnormalities, and is observed in people with cerebral palsy [16]; it is mainly characterized by excessive flexion of the hip, knee, and ankle [17][18][19]. In addition, crouch gait is distinguished in persons with hemiplegia after ischemic stroke [20]. ...
Crouch gait is one of the most common gait abnormalities; it is usually caused by cerebral palsy. There are few works related to the modeling of crouch gait kinematics, crouch gait analysis, and visualization in both the workspace and joint space. In this work, we present a quaternion-based method to solve the forward kinematics of the position of the lower limbs during walking. For this purpose, we propose a modified eight-DoF human skeletal model. Using this model, we present a geometric method to calculate the gait inverse kinematics. Both methods are applied for gait analysis over normal, mild, and severe crouch gaits, respectively. A metric-based comparison of workspace and joint space for the three gaits for a gait cycle is conducted. In addition, gait visualization is performed using Autodesk Maya for the three anatomical planes. The obtained results allow us to determine the capabilities of the proposed methods to assess the performance of crouch gaits, using a normal pattern as a reference. Both forward and inverse kinematic methods could ultimately be applied in rehabilitation settings for the diagnosis and treatment of diseases derived from crouch gaits or other types of gait abnormalities.
... Use of CGA has resulted in a better understanding of the pathomechanics of gait. Indeed, our understanding of gait pathology and its causes, especially in children with CP, has been enhanced through comprehensive gait analysis studies that have documented common patterns of gait in persons with CP [1][2][3]. CGA is an accurate and reliable tool for the objective documentation and understanding of complex gait pathology and is more accurate than visual observation of gait pathology [4,5]. Clinical examination measures correlate poorly with gait deviations in children with CP and, therefore, should not be the sole basis for treatment decision-making to improve gait function [6]. ...
OBJECTIVE: This study assessed the difference in the foot progression angle and measure spatiotemporal parameters of gait of children with diplegic cerebral palsy and to examine the relation among foot progression angle of right and left lower limb and spatiotemporal parameters of gait. DESIGN: Cross-sectional and Correlation study. SUBJECTS: Sixty children with spastic diplegia, aged 5 to 8 years. The participants were categorized into 3 age groups of equivalent number: group A (5 to 6 years), group B (6 to 7 years), as well as group C (7 to 8 years). METHODS: Foot progression angle and spatiotemporal parameters of the gait for both feet were evaluated utilizing a dynamic footprint. RESULTS: a moderate negative significant correlation was noted among left FPA and right step length, and right stride length. There was moderate positive significant correlation among left FPA and cadence . A weak non-significant correlation was observed among right and left FPA and gait parameters among three groups. CONCLUSION: foot progression angle assessment and spatiotemporal measurements and the correlation among them can give objective and quantitative data that could be utilized in rehabilitation and clinical evaluations to identify functional deficiencies.
Computer assisted orthopedic surgery is used to improve precision. Electro‐magnetic tracking has been shown to improve precision in mono‐planar derotational osteotomies. However, studies are lacking to investigate its use in multiplanar osteotomies. For this purpose, 60 complex (derotation and extension) osteotomies were performed in standardized sawbones. Correction amount was randomly planned before the procedures. In 30 bones, the amount of correction was determined intraoperatively using conventional goniometric measurement while in the other 30 bones electro‐magnetic tracking was used to guide the amount of correction. CT‐scans were done before and after the procedures in all bones and the amount of correction was determined to compare the precision of the two techniques. Electromagnetic tracking resulted in a precision of 2.25° ± 1.77° for derotation and 1.38° ± 1.29° for extension, while precision for the conventional method was significantly lower. There was a significant relationship between goniometer measurement deviation and the absolute angle change for derotation and extension measurements with larger deviations for greater angle changes. For the electro‐magnetic tracking, this correlation was observed only for derotation measurement. Electro‐magnetic tracking represents an accurate method to control complex, multiplanar corrective osteotomies with superior precision in comparison to conventional goniometric measurement. Further research is needed to investigate the in‐vivo accuracy and the effects on clinical outcome.
Background
Gait analysis aids in evaluation, classification, and follow-up of gait pattern over time in children with cerebral palsy (CP). The analysis of sagittal plane joint kinematics is of special interest to assess flexed knee gait and ankle joint deviations that commonly progress with age and indicate deterioration of gait. Although most children with CP are ambulatory, no objective quantification of gait is currently included in any of the known international follow-up programs. Is video-based 2-dimensional markerless (2D ML) gait analysis with automated processing a feasible and useful tool to quantify deviations, evaluate and classify gait, in children with CP?
Methods
Twenty children with bilateral CP with Gross Motor Function Classification Scale (GMFCS) levels I–III, from five regions in Sweden, were included from the national CP registry. A single RGB-Depth video camera, sensitive to depth and contrast, was positioned laterally to a green walkway and background, with four light sources. A previously validated markerless method was employed to estimate sagittal plane hip, knee, ankle kinematics, foot orientation and spatio-temporal parameters including gait speed and step length.
Results
Mean age was 10.4 (range 6.8–16.1) years. Eight children were classified as GMFCS level I, eight as II and four as III. Setup of the measurement system took 15 min, acquisition 5–15 min and processing 50 min per child. Using the 2D ML method kinematic deviations from normal could be determined and used to implement the classification of gait pattern, proposed by Rodda et al. 2001.
Conclusion
2D ML assessment is feasible, since it is accessible, easy to perform and well tolerated by the children. The 2D ML adds consistency and quantifies objectively important gait variables. It is both relevant and reasonable to include 2D ML gait assessment in the evaluation of children with CP.
Crouch gait is one of the most common compensatory walking patterns found in individuals with neurological disorders due to their limited physical capacity. Notable kinematic characteristics of crouch gait are excessive knee flexion during stance and reduced range of motion during swing. Knee exoskeletons have the potential to improve crouch gait by providing precisely controlled torque assistance directly to the knee joint. In this study, we implemented a finite-state machine-based impedance controller for a powered knee exoskeleton to provide assistance during both stance and swing for five children/young adults who exhibit chronic crouch gait. The assistance provided a strong orthotic effect, increasing stance phase knee extension by an average of 12°. The knee range of motion during swing was increased by an average of 15°. Changes to spatiotemporal outcomes, such as preferred walking speed and percent stance phase, were inconsistent across subjects and indicative of the underlying intricacies of user response to assistance. This study demonstrates the potential of knee exoskeletons operating in impedance control to mitigate the negative kinematic characteristics of crouch gait during both stance and swing phases of gait.
Deformities of the lower extremity are common in neuromuscular disorders, the acquired consequences of the primary pathology in the brain (e.g., cerebral palsy), the spinal cord (e.g., spina bifida), the peripheral nervous system (e.g., Charcot Marie Tooth syndrome) or the muscle (e.g., muscular dystrophy). The musculoskeletal deformities that arise from these conditions are a result of abnormalities of muscle tone, muscle strength, growth and motor development, motor control, and the impact of these on muscle length, skeletal growth, and remodeling. Although specific deformities might be similar in different neuromuscular conditions, the indications for treatment and the principles of management of these must be considered in the context of the specific disorder, as the impact of specific deformities will vary with the type of disorder (e.g., upper vs. lower motor neuron disorders; static vs. progressive, etc.) as well as the severity of the underlying disorder.
Background
Robotic-assisted gait training (RAGT) devices are effective for children with cerebral palsy (CP). Many RAGT devices have been created and put into clinical rehabilitation treatment. Therefore, we aimed to investigate the safety and feasibility of a new RAGT for children with CP.
Methods
This study is a cross-over design with 23 subjects randomly divided into two groups. The occurrence of adverse events and changes in heart rate and blood pressure were recorded during each AiWalker-K training. Additionally, Gross Motor Function Measure-88 (GMFM-88), Pediatric Balance Scale (PBS), 6 Minutes Walking Test (6MWT), Physiological Cost Index, and Edinburgh Visual Gait Score (EVGS) were used to assess treatment, period, carry-over, and follow-up effects in this study.
Results
Adverse events included joint pain, skin pain, and injury. Heart rate and blood pressure were higher with the AiWalker-K compared to the rest (P < 0.05), but remained within safe ranges. After combined treatment with AiWalker-K and routine rehabilitation treatment, significant improvements in 6MWT, GMFM-88 D and E, PBS, and EVGS were observed compared to routine rehabilitation treatment alone (P < 0.05).
Conclusions
Under the guidance of experienced medical personnel, AiWalker-K can be used for rehabilitation in children with CP.
Case
A 13-year-old adolescent boy with hemiplegic cerebral palsy suffering from fixed knee flexion deformity of 10° despite extensive conservative treatment. Owing to a posterior tibial slope (PTS) of 16°, anterior hemiepiphysiodesis was applied to the proximal tibia. The 2 screws were removed after 9 months. Final follow-up at 16 months showed complete knee extension and a PTS of 4°.
Conclusion
The presented technique is a good alternative in knee flexion deformity with an increased PTS and has surprisingly not been described in the literature. This might be worth considering for other pathologies such as pediatric anterior cruciate ligament injury with an increased PTS.
Background
Children with cerebral palsy (CP) who walk have complex gait patterns and deviations often requiring physical therapy (PT)/medical/surgical interventions. Walking in children with CP can be assessed with 3-dimensional instrumented gait analysis (3D-IGA) providing kinematics (joint angles), kinetics (joint moments/powers), and muscle activity.
Purpose
This clinical practice guideline provides PTs, physicians, and associated clinicians involved in the care of children with CP, with 7 action statements on when and how 3D-IGA can inform clinical assessments and potential interventions. It links the action statement grades with specific levels of evidence based on a critical appraisal of the literature.
Conclusions
This clinical practice guideline addresses 3D-IGA’s utility to inform surgical and non-surgical interventions, to identify gait deviations among segments/joints and planes and to evaluate the effectiveness of interventions. Best practice statements provide guidance for clinicians about the preferred characteristics of 3D-IGA laboratories including instrumentation, staffing, and reporting practices.
Video Abstract: Supplemental digital content available at http://links.lww.com/PPT/A524.
Background
Gait analysis aids in evaluation, classification and follow-up of gait pattern over time in children with cerebral palsy (CP). The sagittal plane is of special interest to assess flexed knee gait and ankle joint deviations that commonly progress with age and indicate deterioration of gait. Although most children with CP are ambulatory, no objective quantification of gait is currently included in any of the known international follow-up programs.
Can video-based 2-dimensional markerless (2D ML) gait analysis with automated processing be feasible for evaluation and classification of gait in children with CP?
Methods
Twenty children with bilateral CP with Gross Motor Function Classification Scale (GMFCS) levels I–III, from five regions in Sweden, were included from the national CP registry. A single RGB-Depth video camera, sensitive to depth and contrast, was positioned laterally to a green walkway and background, with four light sources. A previously validated markerless method was employed to estimate hip, knee and ankle kinematics in the sagittal plane, together with foot orientation in relation to the room, gait speed and step length.
Results
Mean age was 10.4 (range 6.8–16.1) years. Eight children were classified as GMFCS level I, eight as II and four as III. Setup took 15 minutes, acquisition 5–15 minutes and processing 10–15 minutes per child. With the 2D ML method deviations from normal could be determined and used to implement the classification of gait pattern, proposed by Rodda et al. 2001.
Conclusion
2D ML assessment is feasible, since it is accessible, easy to perform and well tolerated by the children. The 2D ML adds consistency and quantifies objectively important gait variables. It is both relevant and reasonable to include 2D ML gait assessment in the evaluation of children with CP.
This study reports the long-term outcomes of hamstring lengthening to treat flexed knee gait in children with ambulatory cerebral palsy (CP) after skeletal maturity. This retrospective longitudinal observational study used instrumented gait analysis (GA) <8 and >15 years old in children with bilateral CP. The primary variable was knee flexion in stance phase. Eighty children (160 limbs) were included; 49% were male, 51% female. Mean age at first GA was 6.0 (SD: 1.2) years and 19.6 (SD: 4.5) years at final GA. Mean follow-up was 13.7 (SD: 4.7) years. Children were classified as Gross Motor Function Classification System I-8, II-46 and III-26. Average Gross Motor Function Measure Dimension D was 72% (SD: 20%). Hamstring lengthenings occurred once in 82, twice in 54 and three times in 10 limbs. From initial to final GA, average knee flexion in stance was unchanged, 27.8° (SD: 14.8°) to final 27.0° (SD: 11.2°; P = 0.54). Knee flexion at foot contact was 39.6° (SD: 13.0°), improving to final GA of 30.7° (SD: 10.6°; P < 0.001). Initial gait deviation index was 65.8 (SD: 31.9), improving to final 78.9 (SD: 28.2; P < 0.001). Older age, males and concomitant plantar flexor lengthening predicted change toward more flexed knee gait. Hamstring lengthening did not lead to back-kneeing gait at maturity while maintaining childhood stance phase knee flexion. A subgroup still developed significant flexed knee gait posture and may have benefited from more aggressive treatment options. This outcome may also be impacted by diverse functional levels, etiologies and treatments of flexed knee gait.
Key Clinical Message
Virtual height exposure coupled with motion capture is feasible to elicit changes in spatiotemporal, kinematic, and kinetic gait parameters in a child with cerebral palsy and should be considered when investigating gait in real‐world‐scenarios.
Purpose
To investigate the effect of dynamic orthotic garments (Thera togs) on foot pressure distribution, postural control, and endurance in children with spastic diplegic CP.
Patients and Methods
This is a single-blind randomized controlled clinical trial involving 34 (8–10 years) with spastic diplegic CP. The control group received conventional physical therapy (CPT), whereas the study group received CPT in addition to wearing TheraTogs. We recorded foot pressure distribution, trunk control measurement scale, trunk position sense, Pediatric Berg Balance Scale (PBS), and six-minute walking distance (6MWD).
Results
Both groups showed improvement. The study group had significant improvement in foot pressure distribution (p-value 0.003, 0.001, <0.001 for forefoot, midfoot, and rearfoot mean pressures respectively, and 0.005, <0.001, and 0.005 for forefoot, midfoot, and rearfoot peak pressures respectively), Pediatric balance scale, The trunk control measurement scale, and Trunk position sense (p-value < 0.001) and six-minute walking distance (p-value 0.029). Our data suggest that adding TheraTogs to conventional physiotherapy improves foot pressure, postural control, and endurance in children with spastic diplegic cerebral palsy.
Conclusion
Both TheraTogs and conventional physical therapy corrected foot pressure distribution, trunk control, improved balance, and increased 6MWD in children with spastic diplegic CP but the improvement was more significant in TheraTogs group.
Clinical Trial Registration
NCT05271149.
Background
Anterior distal femoral hemiepiphysiodesis (ADFH) is a surgical treatment choice to correct flexed knee gait and fixed knee flexion deformities in children with cerebral palsy who are skeletally immature. Increased anterior pelvic tilt has been reported after surgeries that correct knee flexion deformities, including hamstring lengthening (HSL) and distal femoral extension osteotomies, but anterior pelvic tilt has not been studied after ADFH. We hypothesized that anterior pelvic tilt would increase after ADFH, especially when combined with HSL, and it would correlate with the change in minimum knee flexion in stance and dynamic hamstring lengths.
Methods
Thirty-four eligible participants (age: 13.0, SD: 2.0) were included. Change in mean pelvic tilt across the gait cycle was compared as a function of clinical and gait parameters using linear mixed models. The relationship of change in pelvic tilt to change in other variables was examined using Pearson correlation
Results
Overall, anterior pelvic tilt increased significantly after ADFH by 4.4 degrees ( P = 0.02). Further, the analysis revealed anterior pelvic tilt only increased significantly in the group that had concurrent HSL (11.1 degrees, P < 0.001). Overall, minimum knee flexion significantly decreased (increase in knee extension) in stance (−19.1 degrees, P < 0.001) and there was an increase in maximum normalized dynamic hamstring lengths (0.03, P < 0.001). The anterior pelvic tilt increased significantly in Gross Motor Function Classification System levels III to IV (5.9 degrees, P = 0.02) but did not change significantly in Gross Motor Function Classification System I to II (2.5 degrees, P = 0.37). Change in pelvic tilt was correlated with change in maximum dynamic hamstring lengths ( r = 0.87, P < 0.0001) and change in minimum knee flexion in stance ( r = −0.71, P < 0.0001).
Conclusions
Anterior distal hemiepiphysiodesis without concurrent HSL for flexion knee deformities does not result in increased anterior pelvic tilt. Surgeons should consider anterior distal hemiepiphysiodesis in patients with cerebral palsy and flexed knee gait, who preoperatively have long dynamically modeled hamstrings, are skeletally immature, and when maintenance of pelvic tilt is desired.
Level of Evidence
Level III—retrospective comparative study.
Background: For children and adolescents affected by bilateral spastic cerebral palsy (BSCP), non-invasive neurostimulation with repetitive neuromuscular magnetic stimulation (rNMS) combined with physical exercises, conceptualized as functional rNMS (frNMS), represents a novel treatment approach. Methods: In this open-label study, six children and two adolescents (10.4 ± 2.5 years) with BSCP received a frNMS intervention targeting the gluteal muscles (12 sessions within 3 weeks). Results: In 77.1% of the sessions, no side effects were reported. In 16.7%, 6.3% and 5.2% of the sessions, a tingling sensation, feelings of pressure/warmth/cold or very shortly lasting pain appeared, respectively. frNMS was highly accepted by families (100% adherence) and highly feasible (97.9% of treatment per training protocol). A total of 100% of participants would repeat frNMS, and 87.5% would recommend it. The Canadian Occupational Performance Measure demonstrated clinically important benefits for performance in 28% and satisfaction in 42% of mobility-related tasks evaluated by caregivers for at least one follow-up time point (6 days and 6 weeks post intervention). Two patients accomplished goal attainment for one mobility-related goal each. One patient experienced improvement for both predefined goals, and another participant experienced improvement in one and outreach of the other goal as assessed with the goal attainment scale. Conclusions: frNMS is a safe and well-accepted neuromodulatory approach that could improve the quality of life, especially in regard to activity and participation, of children and adolescents with BSCP. Larger-scaled studies are needed to further explore the effects of frNMS in this setting.
Aim: The investigation of satisfaction with using dynamic foot-ankle orthoses, which have an important place in rehabilitation in children with cerebral palsy (CP), is essential for eliminating deficiencies and effectively implementing the use. Our study aims to evaluate the satisfaction level of children with spastic CP by taking their own opinions. Materials and Method: Children with spastic CP aged 5-18 years, who can walk, who have been using dynamic foot-ankle orthosis for at least six months, and who have a cognitive level that can answer questions were included in the study. Orthotic satisfaction was evaluated through 12 questions created under the headings of comfort, visuality, and functionality, and the effects of age, gender, and gross motor functions on orthotic satisfaction were investigated. Results: 105 children with spastic CP with a mean age of 10.8±4.2 years participated in the study. At the end of the study, satisfaction with orthosis was found to be moderate. When the factors affecting orthosis satisfaction were evaluated, it was concluded that functional level affects satisfaction in all three areas. Age is a factor affecting satisfaction primarily related to the visual of the orthosis, and gender does not affect satisfaction. Conclusion: As a result, by taking the opinions of orthosis users, significant findings were obtained in eliminating deficiencies and increasing the duration of use and motivation. In addition, the child-based approach was emphasized. It was concluded that orthotic satisfaction changed with age and gross motor function level, and gender had no effect within the framework of the questions asked.
Aims:
To investigate the reliability, validity, and level of evidence of applying ultrasound in assessing the lower-limb muscles of patients with cerebral palsy (CP).
Method:
Publications in Medline, PubMed, Web of Science, and Embase were searched on May 10, 2023, to identify and examine relevant studies investigating the reliability/validity of ultrasound in evaluating the architecture of CP lower-limb muscles systematically, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines.
Results:
Out of 897 records, 9 publications with 111 CP participants aged 3.8-17.0 years were included (8 focused on intra-rater and inter-rater reliability, 2 focused on validity, and 4 were with high quality). The ultrasound-based measurements of muscle thickness (intra-rater only), muscle length, cross-sectional area, muscle volume, fascicle length, and pennation angle showed high reliability, with the majority of intraclass correlation coefficient (ICC) values being larger than 0.9. Moderate-to-good correlations between ultrasound and magnetic resonance imaging measurements existed in muscle thickness and cross-sectional area (0.62 ≤ ICC ≤ 0.82).
Interpretation:
Generally, ultrasound has high reliability and validity in evaluating the CP muscle architecture, but this is mainly supported by moderate and limited levels of evidence. More high-quality future studies are needed.
Background:
Hamstring lengthening has traditionally been the surgical treatment of choice to correct flexed knee gait in children with cerebral palsy (CP). Improved passive knee extension and knee extension during gait are reported post hamstring lengthening, but concurrent increased anterior pelvic tilt also occurs.
Research question:
Does anterior pelvic tilt increase after hamstring lengthening in children with CP both in the short-term and mid-term, and what predicts increased post-operative anterior pelvic tilt?
Methods:
44 participants were included (age 7.2, SD 2.0 years; 5 GMFCS I, 17 GMFCS II, 21 GMFCS III, 1 GMFCS IV). Mean pelvic tilt was compared between visits, and the effect of potential predictors of change in pelvic tilt was examined using linear mixed models. The relationship of change in pelvic tilt to change in other variables was examined using Pearson correlation.
Results:
Anterior pelvic tilt increased significantly post-operatively by 4.8° (p < 0.001). It remained significantly higher by 3.8° at 2-15 years follow-up (p < 0.001). Change in pelvic tilt was not affected by sex, age at surgery, GMFCS level, assistance during walking, time since surgery, or baseline values of hip extensor strength, knee extensor strength, knee flexor strength, popliteal angle, hip flexion contracture, step length, walking speed, maximum hip power in stance, or minimum knee flexion in stance. Pre-operative dynamic hamstring length was associated with greater anterior pelvic tilt at all visits but did not affect amount of change in pelvic tilt. Patients in GMFCS I-II showed a similar pattern of change in pelvic tilt to GMFCS III-IV.
Signficance:
When considering hamstring lengthening for ambulatory children with CP, surgeons should weigh increased mid-term anterior pelvic tilt post-operatively with the desired outcome of improved knee extension in stance. Patients with neutral or posterior pelvic tilt and short dynamic hamstring lengths pre-operatively have lowest risk of excessive post-operative anterior pelvic tilt.
Background:
Children with cerebral palsy (CP) have demonstrated higher rates of overweight and obesity than their typically developed peers. Limited studies have assessed how being overweight or obese affect lower limb kinematics during gait in these children.
Research question:
How are lower limb kinematics during gait affected in children with CP who progress from a healthy weight to being overweight or obese compared to a well-matched healthy weight CP control group?
Methods:
A retrospective analysis of the movement analysis laboratory database was conducted.Children with CP were included if they were aged between 4 and 17 years at baseline,had a follow-up assessment with a minimum of 12 months between assessments, and had no orthopaedic interventions between assessments. A matched control group of children with CP with the same inclusion criteria, except for a requirement of healthy BMI at follow-up, was included. Temporal-spatial and full 3-dimensional lower limb kinematic data were examined.
Results:
Normalized speed and step length reduced from baseline to follow-up for both groups,with no difference in the amount of change between groups. Children with increased BMI demonstrated increased external hip rotation during stance at follow-up not evident in the control group.
Significance:
Results demonstrated similar changes over time between groups. Increased external hip rotation in children with increased BMI was considered small and within the threshold of error associated with transverse plane kinematics. Our results suggest that being overweight or obese does not result in a meaningful change in lower limb kinematics in children with CP.
Little is known about the influence of mechanical loading on growth plate stresses and femoral growth. A multi-scale workflow based on musculoskeletal simulations and mechanobiological finite element (FE) analysis can be used to estimate growth plate loading and femoral growth trends. Personalizing the model in this workflow is time-consuming and therefore previous studies included small sample sizes (N < 4) or generic finite element models. The aim of this study was to develop a semi-automated toolbox to perform this workflow and to quantify intra-subject variability in growth plate stresses in 13 typically developing (TD) children and 12 children with cerebral palsy (CP). Additionally, we investigated the influence of the musculoskeletal model and the chosen material properties on the simulation results. Intra-subject variability in growth plate stresses was higher in cerebral palsy than in typically developing children. The highest osteogenic index (OI) was observed in the posterior region in 62% of the TD femurs while in children with CP the lateral region was the most common (50%). A representative reference osteogenic index distribution heatmap generated from data of 26 TD children’s femurs showed a ring shape with low values in the center region and high values at the border of the growth plate. Our simulation results can be used as reference values for further investigations. Furthermore, the code of the developed GP-Tool (“Growth Prediction-Tool”) is freely available on GitHub ( https://github.com/WilliKoller/GP-Tool ) to enable peers to conduct mechanobiological growth studies with larger sample sizes to improve our understanding of femoral growth and to support clinical decision making in the near future.
The differential diagnosis in a child with a gait disturbance includes both neurological and non-neurological disorders. The primary care provider must differentiate potential neurological causes such a peripheral neuropathy, myopathy/muscular dystrophy, tethered cord, and disorders of the cerebellum from orthopedic disorders such as a septic joint. A thorough history and physical examination that focuses on the nature of gait abnormality can guide the provider toward appropriate investigations.
Background
Ankle-foot orthoses (AFOs) are frequently prescribed in children with cerebral palsy (CP) to improve their gait. Due to the heterogeneous nature of CP and contradictions among previous studies, it is important to evaluate the AFO-specific effects, as well as explore their effects on different gait patterns.
Research questions
a) What are the prevalence and specific features of AFOs in children with CP? b) How do AFOs affect gait pathology in children with CP? c) What are the pattern-specific effects of AFOs in children with CP?
Methods
A group of 170 patients with CP underwent a three-dimensional gait analysis with and without AFOs (either carbon fiber, rigid, flexible or hinged). The gait profile score, the gait variable scores of the hip, knee and ankle joints, non-dimensional step length and walking speed were used as outcome measures. The AFO-specific effects on the kinematic and kinetic waveforms were investigated using statistical non-parametric mapping (SnPM). Effects were considered relevant when the minimal clinically important difference (MCID) or the standard errors of measurement, for the parameters or the waveforms respectively, were exceeded.
Results
Rigid AFOs were prescribed for more than 80% of the children. Significant beneficial effects were observed for non-dimensional step length and walking speed. Most changes in gait indices were not considered relevant. The SnPM-analyses on the total group and specific gait patterns revealed that walking with AFOs improved the kinematic and kinetic waveforms. These effects were relevant, and were most obvious for crouch, apparent equinus and the total group.
Significance
The use of AFOs improves gait, whether we inspect a total -and thus heterogeneous- group or focus on specific gait patterns. However, focussing on specific parameters (i.e. general gait indices) does not provide a full picture of the AFO-effects.
Benefits of hamstring lengthening surgery on the sagittal plane in children with cerebral palsy have been previously demonstrated, but there is limited information on its effects on the transverse plane. This study compared the effects of medial hamstring lengthening (MHL) with those of medial and lateral hamstring lengthening (MLHL) procedures in the transverse plane. Children with gross motor function classification system (GMFCS) levels I-III who had MHL or MLHL were included. Baseline, short- (1-2 years), and long-term (3+ years) postoperative three-dimensional gait analysis outcomes were compared using analysis of variance. Children were excluded if they had concurrent osteotomies or tendon transfers. One hundred fifty children (235 limbs) were included, with 110 limbs in the MHL group (age 8.5 ± 4.1 years, GMFCS I-27%, II-52%, and III-21%) and 125 limbs in the MLHL group (age 10.0 ± 4.0 years, GMFCS I-23%, II-41%, and III-37%). Time between surgery and short- and long-term follow-up gait analysis was 1.5 ± 0.6 years and 6.6 ± 2.9 years, respectively. Transmalleolar axis became more external after MHL at both short and long terms (P < 0.05), whereas there were only significant differences at long term in MLHL (P < 0.05). Although hamstring lengthening has a positive impact on stance phase knee extension in children with cerebral palsy, intact lateral hamstrings after MHL likely contribute to increased tibial external rotation after surgery. Significant increases in external rotation at the knee in the long term are likely related to a trend present with growth in children with cerebral palsy rather than a direct result of surgical intervention.
Background:
Children with cerebral palsy (CP) at Gross Motor Function Classification System (GMFCS) levels III/IV are at risk for losses in standing function during adolescence and transition to adulthood. Multilevel surgery (MLS) is an effective treatment to improve gait, but its effects on standing function are not well documented. The objectives of our study were to describe standing function in children with CP classified as GMFCS levels III/IV and evaluate change after MLS.
Methods:
This retrospective study included children with CP (GMFCS III/IV) ages 6 to 20 years who underwent instrumented gait analysis. A subset who underwent MLS were evaluated for change. Primary outcome measures were Gross Motor Function Measure dimension D, gait velocity, functional mobility scale, and the Pediatric Outcomes Data Collection Instrument (PODCI). Additional impairment level measures included foot pressure, knee extension during stance phase of gait, and knee extension passive range of motion.
Results:
Four hundred thirty-seven instrumented gait analysis sessions from 321 children with CP (ages 13.7±4.8 y; GMFCS III-81%/IV-19%) were included. The GMFCS III group had higher Gross Motor Function Measure dimension D, gait velocity, PODCI scores, and better knee extension compared with the GMFCS IV group (P<0.05); 94 MLS were evaluated for postoperative change 15.3±4.2 months after MLS. Children at GMFCS level III had improved PODCI scores (P<0.05), better knee extension passive range of motion (P<0.01), and improved coronal plane foot pressure (P<0.05) post MLS. Maximum knee extension during stance and heel impulse improved significantly in both groups (P<0.01).
Conclusions:
Standing function of children with CP at GMFCS IV was significantly more limited than at GMFCS III. After MLS, both groups (III/IV) showed improvement in impairment level outcomes (knee extension and foot position), whereas only those functioning at GMFCS III had improvement in activity/participation outcomes according to the PODCI. For children with CP at GMFCS levels IV, MLS may improve standing function, but appropriate goals related to assisted standing and measurement protocols sensitive to limited functional mobility should be adopted.
Level of evidence:
Level III-retrospective comparative study.
Background/aim: Cerebral Palsy (CP) is the most frequent cause of physical disability in childhood. CP causes primary deficits such as impairments in muscle tone, muscle weakness, problems in selective motor control and secondary deficits such as contractures
and deformities. These deficits lead to motor disorders during movement causing limitations in gait. Sixty percent of children with CP can walk independently despite these problems, however, they present with various gait abnormalities. Gait analysis is used in the
quantitative assessment of gait disturbances providing functional diagnosis, assessment for treatment, planning, and monitoring of progress. G-Walk is a wearable sensor device which provides quantitative gait analysis via spatiotemporal parameters and pelvic girdle
angles. In literature, there is no study investigating the reliability of the G-Walk in children with CP. The purpose of this study was to confirm the test-retest reliability of a commercially available body-worn sensor ‘BTS G-WALK sensor system’ for spatiotemporal gait
parameters in children with CP.
Materials and methods: Fifty-four children with CP (mean age: 9.19 ± 3.49 years), Gross Motor Function Classification System (GMFCS) level I-II completed the test-retest protocol with 5 days between tests. The test-retest reliability was calculated using intra-class
correlation coefficients (ICC). Minimal detectable changes were calculated using standard error measurements.
Results: According to the analysis, ICC varied from 0.799 to 0.977 in all of the gait parameters. The statistical analysis showed that all G-Walk parameters’ measurements were found to have almost perfect test-retest reliability.
Conclusion: The G-Walk was found to be reliable in gait parameters for children with CP between ages 5 and 15, in GMFCS level I-II. gait analysis carried out with the G-Walk system is a reliable method to assess gait in children with CP in a clinical setting.
The aim of this study was to determine if gait analysis improves correction of excessive hip internal rotation in ambulatory children with spastic cerebral palsy (CP).
Children undergoing orthopedic surgery were randomized to receive or not receive a preoperative gait analysis report. This secondary analysis included all participants whose gait report recommended external femoral derotation osteotomy (FDRO). One-year postoperative, and pre- to postoperative change in femoral anteversion, mean hip rotation in stance, and mean foot progression in stance were compared between groups and in subgroups based on whether the recommendation for FDRO was followed.
Outcomes did not differ between the group which received a gait report (n=39; 19 males, 20 females; mean age 10y 4mo [SD 3y]; hemiplegia, 3; di/triplegia, 28; quadriplegia, 8; Gross Motor Function Classification System [GMFCS]: level I, 5; level II, 12; level III 19; level IV, 3) and the control group (n=26; 14 males, 12 females; mean age 9y 5mo [SD 2y 10mo]; hemiplegia, 1; di/triplegia, 21; quadriplegia, 4; GMFCS: level I, 4; level II, 1; level III, 9; level IV, 2; all p values >0.29), but improved more in the gait report subgroup in which the FDRO recommendation was followed (seven limbs; change in anteversion −32.9°, hip rotation −25.5°, foot progression −36.2°) than in the control group (anteversion −12.2°, hip rotation −7.6°, foot progression −12.4°; all p values ≤0.02) and the gait report subgroup in which FDRO was not performed (32 limbs; anteversion −1.0°, hip rotation 0.5°, foot progression −8.0°; all p values ≤0.003). Postoperative measures became normal only in the gait report subgroup in which the recommended FDRO was performed.
Gait analysis can improve outcomes when its recommendations are incorporated in the treatment plan.
To address the need for a standardized system to classify the gross motor function of children with cerebral palsy, the authors developed a five-level classification system analogous to the staging and grading systems used in medicine. Nominal group process and Delphi survey consensus methods were used to examine content validity and revise the classification system until consensus among 48 experts (physical therapists, occupational therapists, and developmental pediatricians with expertise in cerebral palsy) was achieved. Interrater reliability (k) was 0.55 for children less than 2 years of age and 0.75 for children 2 to 12 years of age. The classification system has application for clinical practice, research, teaching, and administration.
To address the need for a standardized system to classify the gross motor function of children with cerebral palsy, the authors developed a five-level classification system analogous to the staging and grading systems used in medicine. Nominal group process and Delphi survey consensus methods were used to examine content validity and revise the classification system until consensus among 48 experts (physical therapists, occupational therapists, and developmental pediatricians with expertise in cerebral palsy) was achieved. Interrater reliability (kappa) was 0.55 for children less than 2 years of age and 0.75 for children 2 to 12 years of age. The classification system has application for clinical practice, research, teaching, and administration.
Twenty-eight children with cerebral palsy had two gait analyses an average of 4.4 years apart with no surgical intervention between the tests. The effects of growth and age were examined using three-dimensional kinematics, temporal and stride parameters, and clinical examination measures. Kinematic changes showed decreases in hip, knee, and ankle sagittal plane ranges of motion (ROM), peak hip flexion in swing, and peak knee flexion over time. Temporal and stride parameters showed declines in timing of toe off, cadence, and walking velocity. Clinical measures showed declines in hip abduction ROM (knees flexed and extended), popliteal angle, and sagittal plane ankle ROM (knees flexed and extended). Overall results showed that gait function in these individuals with cerebral palsy decreased longitudinally with respect to temporal/stride measures, passive ROM, and kinematic parameters compared with a group of individuals who had had orthopaedic intervention.
Lack of a valid classification of severity of cerebral palsy and the absence of longitudinal data on which to base an opinion have made it difficult to consider prognostic issues accurately.
To describe patterns of gross motor development of children with cerebral palsy by severity, using longitudinal observations, as a basis for prognostic counseling with parents and for planning clinical management.
Longitudinal cohort study of children with cerebral palsy, stratified by age and severity of motor function and observed serially for up to 4 years during the period from 1996 to 2001.
Nineteen publicly funded regional children's ambulatory rehabilitation programs in Ontario.
A total of 657 children aged 1 to 13 years at study onset, representing the full spectrum of clinical severity of motor impairment in children with cerebral palsy.
Severity of cerebral palsy, classified with the 5-level Gross Motor Function Classification System; function, formally assessed with the Gross Motor Function Measure (GMFM).
Based on a total of 2632 GMFM assessments, 5 distinct motor development curves were created; these describe important and significant differences in the rates and limits of gross motor development among children with cerebral palsy by severity. There is substantial within-stratum variation in gross motor development.
Evidence-based prognostication about gross motor progress in children with cerebral palsy is now possible, providing parents and clinicians with a means to plan interventions and to judge progress over time. Further work is needed to describe motor function of adolescents with cerebral palsy.
There is still some debate regarding the role of 3-dimensional gait analysis in routine preoperative evaluation of children with cerebral palsy. The aim of this prospective study was to evaluate to what extent introduction of 3-D gait analysis changes preoperative surgical planning.
Before gait analysis, 60 ambulatory children aged 10 (4-18) years with spastic cerebral palsy had a specific surgical plan outlined, based on clinical examination by orthopedic surgeons. After gait analysis, the proposed surgical procedures were reviewed to determine the frequency with which the treatment plans changed. A multidisciplinary team assessed the gait analysis.
Treatment plans for 42 of the 60 patients were altered after gait analysis. Surgical treatment was recommended for 49 patients whereas 11 were recommended non-surgical treatment. Of the 253 specific surgical procedures proposed, 97 procedures were not recommended after gait analysis and 65 additional procedures were recommended after the analysis. Thus, the number of procedures proposed was reduced by 13%. A total of 318 specific surgical procedures were proposed either clinically, by gait analysis, or both. There was overall agreement between the referring orthopedic surgeons and gait analysis in 156 of these 318 procedures (49%). Gait analysis proposed more surgery for psoas tenotomy and rectus femoris transfer, whereas less surgery was proposed for other soft tissue and bony procedures. There was good accordance between gait analysis recommendations and the surgery performed subsequently (92%).
Gait analysis provided important additional information that modified preoperative surgical planning to a high degree. The high accordance between recommendations and surgery performed suggests that surgeons seriously consider the gait data and treatment recommendations.
The Gross Motor Function Classification System (GMFCS) for cerebral palsy has been widely used internationally for clinical, research, and administrative purposes. This paper recounts the ideas and work behind the creation of the GMFCS, reports on the lessons learned, and identifies some philosophical challenges inherent in trying to develop an ordered, valid, and consistent system to describe function in children and adolescents with developmental differences. It is hoped that these ideas will be useful to others who choose to expand the field with additional systems in other areas of childhood neurodisability.
Physical therapists frequently use the 66-item Gross Motor Function Measure (GMFM-66) with the Gross Motor Function Classification System (GMFCS) to examine gross motor function in children with cerebral palsy (CP). Until now, reference percentiles for this measure were not available. The aim of this study was to improve the clinical utility of this gross motor measure by developing cross-sectional reference percentiles for the GMFM-66 within levels of the GMFCS.
A total of 1,940 motor measurements from 650 children with CP were used to develop percentiles. These observations were taken from a subsample, stratified by age and GMFCS, of those in a longitudinal cohort study reported in 2002. A standard LMS (skewness-median-coefficient of variation) method was used to develop cross-sectional reference percentiles.
Reference curves were created for the GMFM-66 by age and GMFCS level, plotted at the 3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th, and 97th percentiles. The variability of change in children's percentiles over a 1-year interval also was investigated.
The reference percentiles extend the clinical utility of the GMFM-66 and GMFCS by providing for appropriate normative interpretation of GMFM-66 scores within GMFCS levels. When interpreting change in percentiles over time, therapists must carefully consider the large variability in change that is typical among children with CP. The use of percentiles should be supplemented by interpretation of the raw scores to understand change in function as well as relative standing.
The authors retrospectively reviewed a series of 492 consecutive cerebral palsy patients undergoing computerized motion analysis. The prevalence of 14 specific gait abnormalities was evaluated and compared based on involvement (hemiplegia, diplegia, or quadriplegia), age, and history of previous surgery (lower extremity orthopaedic surgery or rhizotomy). Stiff knee in swing, equinus, and intoeing were all seen in more than 50% of the subjects in each of the hemiplegic, diplegic, and quadriplegic groups. Increased hip flexion and crouch were also present in more than 50% of the subjects in the diplegic and quadriplegic groups, and hip adduction occurred in more than 50% of the quadriplegic subjects. The likelihood of having stiff knee in swing, out-toeing, calcaneus deformity, and crouch increased with prior surgery. The likelihood of having rotational malalignment of the leg (internal hip rotation with out-toeing), calcaneus, out-toeing, varus and valgus foot deformities, and hip internal rotation increased with age. These findings provide important information for counseling ambulatory children with cerebral palsy and their families.
The aim of this study was to examine differences in gait kinematics and spatiotemporal parameters in ambulatory children and adolescents with bilateral spastic cerebral palsy (BSCP) among Gross Motor Function Classification System (GMFCS) levels I-III.
A retrospective review was conducted of individuals with BSCP who had three-dimensional motion analysis (3DGA) at one of seven pediatric hospitals. Means and standard deviations of each gait parameter were stratified by GMFCS levels (I-III) and for a typically developing comparison group.
Data from 292 children and adolescents with BSCP (189 males, 103 females; mean age 13y) were compared to a typically developing comparison group (24 male, 26 female; mean age 10y 6mo). Gait patterns differed from typically developing in all GMFCS levels, with increasing deviation as GMFCS level increased in 21 out of 28 parameters. Despite significant differences in selected mean kinematic parameters among GMFCS levels such as knee angle at initial contact of 24°, 29°, and 41° in GMFCS levels I, II and III respectively, there was also substantial overlap among GMFCS levels.
GMFCS levels cannot be identified using specific gait kinematics. Treatment decisions should be guided by comprehensive 3DGA that allows measurement of gait impairments at the joint level for each individual.
© 2015 Mac Keith Press.
Eighteen children with diplegic cerebral palsy and no history of orthopaedic surgery had two gait analyses a mean of 6.3 years apart to analyse the effects of time on their gait. The mean age of the children at first analysis was 7.7 years (range 4.4-13.3 years). The data was analysed as a whole group (18 children) and as two sub-groups of nine children: those with a shorter follow-up (mean 5.0 years) and those with a longer follow-up (mean 7.5 years) between analyses. The following significant bilateral changes were seen in the whole group and longer follow-up sub-group: deterioration in the range of knee flexion, mid-stance knee flexion, peak knee extension in stance and hamstring length and an improvement in mean and maximum hip rotation. Temporal data showed no significant changes once normalised. There were no bilateral significant changes in data from children evaluated at a mean of 5 years follow-up. GMFCS scores generally improved over time despite the significant increase in flexed knee gait. There was no significant change in gait deviation index in any group over time. There was an increase in body mass index in 16 children but there was no correlation between this and the degree of mid-stance knee flexion. These findings may have implications for longer term follow-up of children with cerebral palsy into adulthood.
The aim of this study was to validate the expanded and revised Gross Motor Function Classification System (GMFCS-E&R) for children and youth with cerebral palsy using group consensus methods. Eighteen physical therapists participated in a nominal group technique to evaluate the draft version of a 12- to 18-year age band. Subsequently, 30 health professionals from seven countries participated in a Delphi survey to evaluate the revised 12- to 18-year and 6- to 12-year age bands. Consensus was defined as agreement with a question by at least 80% of participants. After round 3 of the Delphi survey, consensus was achieved for the clarity and accuracy of the descriptions for each level and the distinctions between levels for both the 12- to 18-year and 6- to 12-year age bands. Participants also agreed that the distinction between capability and performance and the concept that environmental and personal factors influence methods of mobility were useful for classification of gross motor function. The results provide evidence of content validity of the GMFCS-E&R. The GMFCS-E&R has utility for communication, clinical decision making, databases, registries, and clinical research.
A longitudinal study over a mean of 32 months was conducted on 18 subjects with spastic diplegia, ranging in age from 4 to 14 years. Three-dimensional gait analyses were performed to compare the temporal and kinematic data across the two time intervals. The comparison revealed a deterioration of gait stability evidenced by increases in double support and decreases in single support with time and growth (p < 0.05). Kinematic analysis revealed a loss of excursion about the knee, ankle, and pelvis (p < 0.05). Additionally, passive range-of-motion analysis revealed a decrease in the popliteal angle over time (p < 0.05). In conclusion, this longitudinal investigation revealed that, in contrast to the gait of children with intact motor function, ambulatory ability tends to worsen over time in spastic cerebral palsy. Insight into the natural progression of gait function in cerebral palsy is essential when evaluating the change in motor status over time or the effects of an intervention in this population.
The purpose of this study was to compare surgical recommendations made by clinicians experienced in gait analysis when using information provided from the clinical examination and videotape, with recommendations made after the addition of kinematic, kinetic, and electromyographic (EMG) data. Ninety-one patients with a diagnosis of cerebral palsy were seen in the gait laboratory as part of the surgical decision-making process. Experienced clinicians reviewed video and clinical examination data for each patient and made surgical recommendations. Joint kinematics and kinetics and EMG data were then reviewed, and a second set of surgical recommendations was made. Comparisons between these recommendations showed that the addition of gait-analysis data resulted in changes in surgical recommendations in 52% of the patients, with an associated reduction in cost of surgery, not to mention the human impact of an inappropriate surgical decision, which is more likely without gait analysis. When changes in recommendations were made, an increase in surgical recommendations was observed for the gastrocnemius (59%) and rectus femoris (65%), whereas decreases were observed for the hamstrings (61%), psoas (78%), hip adductors (83%), femur (86%), and tibia (64%).
The impact of preoperative gait analysis on the orthopaedic care of 97 patients (101 gait analyses) at the authors' institution was evaluated. For the 70 patients for whom a specific treatment plan had been outlined before the preoperative gait study, the treatment plan was altered in 62 (89%) after the gait analysis study. In 10 of the 70 patients with specific treatment plans before the gait study, the referring physician also served as the physician in the gait laboratory; ultimate treatment was changed in nine of these 10 patients. Of the 273 surgical procedures recommended before the gait study in the 70 patients, 106 (39%) of these procedures were not done when the gait laboratory data were considered. An average of 1.5 procedures per patient that were planned before the gait study ultimately were not deemed necessary by the treating physician after the addition of the gait data. An additional 110 procedures (1.6 per patient) that had not been recommended before the gait study ultimately were performed after addition of the gait laboratory data. This study shows that ultimate surgical intervention frequently is altered by the addition of gait laboratory data.
The impact of postoperative gait analysis on the ongoing orthopaedic care of 38 consecutive patients with a static encephalopathy was evaluated. Of the 38 postoperative gait analyses, 32 (84%) resulted in recommendations of a change in patient care. Surgery was recommended in 16 of 38 (42%) cases, bracing in 20 (53%) cases, and specific physical therapy regimens in eight (21%) cases. Eleven of the 38 (29%) patients had changes recommended in at least two of the three areas (surgery, bracing, and therapy). The results of this study suggest that postoperative gait analysis serves not only as a measure of treatment outcome, but also as a useful tool in planning ongoing care for these patients.
This study explored the relationships between the Gross Motor Function Classification System (GMFCS), limb distribution, and type of motor impairment. Data used were collected in the Ontario Motor Growth study, a longitudinal cohort study with a population-based sample of children with cerebral palsy (CP) in Canada (n=657; age 1 to 13 years at study onset). The majority (87.8%) of children with hemiplegia were classified as level I. Children with a bilateral syndrome were represented in all GMFCS levels, with most in levels III, IV, and V. Classifications by GMFCS and 'limb distribution' or by GMFCS and 'type of motor impairment' were statistically significantly associated (Pearson's chi2 p<0.001), though the correlation for limb distribution (two categories) by GMFCS was low (tau-b=0.43). An analysis of function (GMFCS) by impairment (limb distribution) indicates that the latter clinical characteristic does not add prognostic value over GMFCS. Although classification of CP by impairment level is useful for clinical and epidemiological purposes, the value of these subgroups as an indicator of mobility is limited in comparison with the classification of severity with the GMFCS.
The authors retrospectively reviewed a series of 492 consecutive cerebral palsy patients undergoing computerized motion analysis. The prevalence of 14 specific gait abnormalities was evaluated and compared based on involvement (hemiplegia, diplegia, or quadriplegia), age, and history of previous surgery (lower extremity orthopaedic surgery or rhizotomy). Stiff knee in swing, equinus, and intoeing were all seen in more than 50% of the subjects in each of the hemiplegic, diplegic, and quadriplegic groups. Increased hip flexion and crouch were also present in more than 50% of the subjects in the diplegic and quadriplegic groups, and hip adduction occurred in more than 50% of the quadriplegic subjects. The likelihood of having stiff knee in swing, out-toeing, calcaneus deformity, and crouch increased with prior surgery. The likelihood of having rotational malalignment of the leg (internal hip rotation with out-toeing), calcaneus, out-toeing, varus and valgus foot deformities, and hip internal rotation increased with age. These findings provide important information for counseling ambulatory children with cerebral palsy and their families.
Hip displacement is considered to be common in children with cerebral palsy but the reported incidence and the proposed risk factors vary widely. Knowledge regarding its overall incidence and associated risk factors can facilitate treatment of these children.
An inception cohort was generated from the Victorian Cerebral Palsy Register for the birth years 1990 through 1992, inclusive, and multiple data sources pertaining to the cohort were reviewed during 2004. Gross motor function was assessed for each child and was graded according to the Gross Motor Function Classification System (GMFCS), which is a valid, reliable, five-level ordinal grading system. Hip displacement, defined as a migration percentage of >30%, was measured on an anteroposterior radiograph of the pelvis with use of a reliable technique.
A full data set was obtained for 323 (86%) of 374 children in the Register for the birth years 1990 through 1992. The mean duration of follow-up was eleven years and eight months. The incidence of hip displacement for the entire birth cohort was 35%, and it showed a linear relationship with the level of gross motor function. The incidence of hip displacement was 0% for children with GMFCS level I and 90% for those with GMFCS level V. Compared with children with GMFCS level II, those with levels III, IV, and V had significantly higher relative risks of hip displacement (2.7, 4.6, and 5.9, respectively).
Hip displacement is common in children with cerebral palsy, with an overall incidence of 35% found in this study. The risk of hip displacement is directly related to gross motor function as graded with the Gross Motor Function Classification System. This information may be important when assessing the risk of hip displacement for an individual child who has cerebral palsy, for counseling parents, and in the design of screening programs and resource allocation.
Outcome in 24 ambulant children with spastic diplegic cerebral palsy, in whom multilevel surgical intervention was recommended following gait analysis, is reviewed. Twelve children had surgical intervention (treatment group; eight males, four females; mean age 9 years 10 months, SD 3 years 4 months) while the other 12 did not (control group; five males, seven females; mean age 10 years 1 month, SD 2 years 11 months). All children had interval three-dimensional gait analyses (mean time between analyses: control group, 14.1 months; treatment group, 17.9 months). At follow-up the control group (mean age 11 years 9 months) showed a significant increase in minimum hip and knee flexion in stance which was not related to age, the interval between analyses, changes in the passive joint range of motion, nor changes in anthropometric measurements. The treatment group (mean age at follow-up 11 years 3 months) showed a significant improvement in minimum knee flexion and in ankle dorsiflexion in stance. Parents of nine children said their child's walking distance had increased following intervention. Of five children using posterior walkers preoperatively, two continued to use them postoperatively; two were using crutches or sticks and the remaining child walked independently. Two children who walked independently preoperatively used sticks postoperatively for community ambulation. The deterioration seen in the kinematics of the control group suggests that previous outcome studies comparing postoperative gait with preoperative gait have underestimated the immediate effects of surgery. It also raises concerns about the long-term effects of surgical intervention.
This study investigates the optimum number of gait trial recordings to maximise intra-rater reliability with the CODA motion analysis system in a normal population. Potential sources of variability in test-retest experimental procedures will be discussed.
The most recent study by [Maynard V, Bakheit AMO, Oldham J, Freeman J. Intra-rater and inter-rater reliability of gait measurements with CODA mpx30 motion analysis system. Gait Posture 2003;17:59-67] that evaluated the Cartesian Optoelectronic Dynamic Anthropometer (CODA) motion analysis system exhibited poor correlation for intra-rater reliability of kinematic and kinetic parameters. It is unknown what the optimum number of gait trials is required during testing to represent an individuals gait pattern during normal walking.
Ten healthy subjects (mean 28.5 years) were tested on two occasions by an experienced well trained rater during normal walking to establish intra-rater reliability using 1-2, 1-4, 1-6, 1-8, and 1-10 gait trial recordings to represent the mean. The 3D kinematic, kinetic parameters of hip, knee and ankle joints and spatio-temporal parameters were recorded during normal walking. Intra-class correlation coefficient and Bland and Altman limits of agreement were chosen to analyse the results.
Spatio-temporal parameters exhibited least test-retest variability, as measurement of only two gait trials to represent the mean produced similar variability in test-retest as when higher numbers of trials were measured. Kinematic parameters were more variable than kinetic while for both variability decreased with increasing numbers of trials measured and would advocate measuring 10 gait trials for future analysis when measuring these parameters.
Generally intra-rater reliability improves when larger number of gait trial recordings represent a subject's gait.
The aim of the present study was to assess the outcome of orthopaedic surgery in ambulant children with cerebral palsy, when the orthopaedic surgeons followed the recommendations from preoperative three-dimensional gait analysis. 55 children, mean age 10 y 11 mo, were clinically evaluated by orthopaedic surgeons who proposed a surgical treatment plan. After gait analysis and subsequent surgery, three groups were defined. In group A, there was agreement between clinical proposals, gait-analysis recommendations, and subsequent surgery in 128 specific surgical procedures. In group B, 54 procedures were performed based on gait analysis, although these procedures had not been proposed at the clinical examination. In group C, 55 surgical procedures that had been proposed after clinical evaluation were not performed because of the gait-analysis recommendations. The children underwent follow-up gait analysis 1 to 2 years after the initial analysis. The kinematic results were satisfactory, with improvement in most of the gait parameters in children who had undergone surgery and no significant deterioration in those who were not operated. In group A, there were significant improvements in maximum hip extension in stance, minimum knee flexion in stance, timing of maximum knee flexion in swing and knee range of motion, maximum ankle dorsiflexion in stance, and mean femur rotation in stance. In group B, there were significant improvements in maximum hip extension in stance, minimum knee flexion in stance, and knee range of motion. We conclude that gait analysis was useful in confirming clinical indications for surgery, in defining indications for surgery that had not been clinically proposed, and for excluding or delaying surgery that was clinically proposed.
Limb distribution, motor impairment, and functional classification of cerebral palsy
- Gorter
Alterations in surgical decision making in patients with cerebral palsy based on three-dimensional gait analysis
- DeLuca
Variation in kinematic and spatiotemporal gait parameters by Gross Prevalence of Gait Abnormalities in CP Susan A Rethlefsen
- S Ounpuu
- G Gorton
- A Bagley
Ounpuu S, Gorton G, Bagley A, et al. Variation in kinematic and spatiotemporal gait parameters by Gross
Prevalence of Gait Abnormalities in CP Susan A Rethlefsen et al. 9
Motor Function Classification System level in children and adolescents with cerebral palsy
Motor Function Classification System level in children
and adolescents with cerebral palsy. Dev Med Child Neurol 2015; 57: 955-62.
Development and reliability of a system to classify gross motor function in children with cerebral palsy
- Palisano