Article

Kinematic adaptation and changes in gait classification in running compared to walking in children with unilateral spastic cerebral palsy

Authors:
  • KIZ Chiemgau
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Abstract

Background Classification of sagittal gait patterns in unilateral spastic cerebral palsy (CP) provides direct implication for treatment. Five types are described: type 0 has minor gait deviation; type 1 has inadequate ankle dorsiflexion in swing; type 2 has inadequate ankle dorsiflexion throughout the gait cycle; types 3 and 4 have abnormal function of the knee and hip joint respectively. During gait analysis of children with unilateral spastic CP we observed frequently that a knee flexion deficit disappeared during running. That may have an impact on classification and treatment. Research question Does the classification type change while running and how do patients’ kinematics adapt to running? Methods 64 children with unilateral spastic CP were classified using instrumented gait analysis for walking and running. The deviation of four parameters from typically developing children (TD) were used to distinguish between types: peak ankle dorsiflexion in swing for type 1, peak ankle dorsiflexion in stance for type 2, knee range of motion for type 3, and hip range of motion for type 4. A three-factor ANOVA for factors group (CP/TD), locomotion (walk/run) and limb side (in-/uninvolved) was conducted. Results The number of patients with type 1, 3 and 4 decreased considerably from walking to running, whereas, the number of type 0 and 2 patients increased. The ANOVA showed that three of four parameters of patients’ pathologic limb adapt similarly to TD to running, except for the ankle dorsiflexion in stance. Significance Running shows that there is a natural way to resolve abnormalities. Therefore, recommended treatments of hip and knee joint abnormalities based on the walking classification can be questioned and additional running analysis may be important for surgical decision making.

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... The subgroup analysis of prevalence of equinus foot based on study design is presented in Figure 4. Certain designs had only one study, and therefore, they were not reliable in estimating the overall prevalence rate of equinus foot in CP. Meanwhile, 14 studies were cohort in design, and they had an overall prevalence rate of 62% (95% CI: 47-74%; I 2 = 98%, p < 0.01) [6,17,20,24,25,27,28,[30][31][32][33][34][35][36]. On the other hand, 4 studies were case series in design, with an overall prevalence rate of 92% (95% CI: 34-100%; I 2 = 84%, p < 0.01) [18,19,21,29]. ...
... Quality assessment of the included studies was conducted by the NIH quality assessment tool for each distinctive study design. A total of 16 studies were of fair quality (moderate risk of bias) [6,7,17,20,22,24,25,28,[30][31][32][33][34][35][36][37], 4 studies were of poor quality (high risk of bias) [18,19,21,29], and 2 studies were of good quality (low risk of bias) [23,26]. ...
... The overall number of included patients with CP in our study is 3595 patients and 4814 limbs/feet, ranging from 7 patients in the study of Goncalves et al. [22] to 1147 patients in the study of Naidu et al. [28]. Most of the included studies reported the data of patients with the spastic type of CP (15 studies) [6,7,[19][20][21][22][23][24][25][26][27][28]30,31,35]. The age of CP patients among included studies ranged from a mean of 3.8 years (with SD of 2) in the study of Boulay et al. [17] to 18.2 years (with SD of 9.9) in the study of Horsch et al. [6]. ...
Article
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Background: Equinus is a common foot deformity in patients with cerebral palsy (CP). However, its prevalence is scarcely reported in the literature. Therefore, we conducted this review to estimate the prevalence of equinus foot in CP. Methods: Eight databases were searched. Our primary outcome was the prevalence of equinus foot in CP patients. Subgroup analysis was conducted based on study design, the laterality of CP, and whether equinus foot was defined or not. Results: The prevalence of equinus foot in CP was 93% (95% CI: 71-99). The prevalence was 99% (95% CI: 55-100), 96% (95% CI: 57-100), and 65% (95% CI: 37-86) in unilateral, both, and bilateral CP, respectively. Based on study design, equinus foot prevalence was 92% (95% CI: 34-100) in case series and 62% (95% CI: 47-74) in cohort studies. Four studies reported definition criteria for equinus foot, with a pooled prevalence rate of equinus foot of 99% (95% CI: 36-100) compared to a rate of 89% (95% CI: 59-98) among studies that lacked a definition criterion. Conclusions: This is the first meta-analysis to address the prevalence of equinus foot in CP patients. Although its prevalence is very high, our findings should be interpreted with caution due to the presence of multiple limitations, such as the lack of standardized definition criteria for equinus foot, the inappropriate study design, the wide confidence interval of equinus foot rate, and the small number of studies investigating it as a primary outcome.
... Odrzucono: jedną pracę przeglądową (Chappell et al., 2019a), dwie publikacje, których tematyka była pośrednio związana z analizą biegu (Chappell et al., 2019c;Verschuren et al., 2007), dwa opisy przypadków (Lee et al., 2013;Lewis, 2017) i dwie publikacje, w których grupa badana nie spełniała kryteriów włączenia do przeglądu piśmiennictwa -sportowcy z MPD (Kloyiam et al., 2011;Runciman et al., 2016). Pozostałe siedem publikacji zostało włączonych do szczegółowej analizy pełnej treści (Böhm i Döderlein, 2012;Chappell et al., 2020Chappell et al., , 2019bDavids et al., 1998;Gibson et al., 2018;Iosa et al., 2013;Krätschmer et al., 2019). W opisanych badaniach wzięło udział łącznie 231 osób z MPD (132 chłopców) w wieku od 4. do 18. ...
... W czterech badaniach wykazano, że prędkość biegu była istotnie niższa u dzieci z MPD niż u ich zdrowych rówieśników (Chappell et al., 2019b;Davids et al., 1998;Iosa et al., 2013;Krätschmer et al., 2019). Podczas przejścia z fazy chodu do fazy biegu strategią zwiększenia prędkości u dzieci z MPD było zwiększenie kadencji kroku, w przeciwieństwie do ich zdrowych rówieśników, którzy w tym celu wydłużali długość kroku (Davids et al., 1998;Iosa et al., 2013). ...
... Podczas przejścia z fazy chodu do fazy biegu strategią zwiększenia prędkości u dzieci z MPD było zwiększenie kadencji kroku, w przeciwieństwie do ich zdrowych rówieśników, którzy w tym celu wydłużali długość kroku (Davids et al., 1998;Iosa et al., 2013). W czterech badaniach analizowano długość kroku podczas biegu u dzieci z MPD (Davids et al., 1998;Böhm i Döder lein, 2012;Iosa et al., 2013;Krätschmer et al., 2019). W trzech z nich wykazano, że jest ona krótsza u dzieci z MPD niż u ich zdrowych rówieśników (Davids et al., 1998;Iosa et al., 2013;Krätschmer et al., 2019). ...
Article
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Introduction: Children with cerebral palsy present with diverse mobility abnormalities which are classified at the levels of structure and function and activity according to the International Classification of Functioning, Disability and Health. The authors of most studies on independent mobility in children with cerebral palsy have focused on gait abnormalities. The aim of this literature review was to analyse the running ability in children with cerebral palsy. Methods: A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. A search of the PubMed database was performed using the terms “cerebral palsy” and “running.” Results: Children with cerebral palsy run at a lower speed compared to their healthy peers. They have a shorter stride length. The power generated by various muscle groups is different from that observed in typically developing children. This results in different kinematics and hence lower quality of running. Implementation of training focused on running as part of the rehabilitation process in children with cerebral palsy may bring positive results. Discussion: The ability of running is important not only to move quickly but also to participate in the activities of daily living performed by typically developing children. Because of that, it is advisable to incorporate elements of running training into the rehabilitation process in children with cerebral palsy, whenever possible.
... Conditions such as stroke, brain injury, and cerebral palsy (CP) affect upper motor neuronal pathways [1] and are collectively referred to as pathologies of central neurological origin. Foot-drop is a common impairment seen across these conditions; it is seen in 30% of people with stroke [2] and 64% with unilateral spastic CP [3]. Foot-drop may result in walking being slower, less efficient and potentially unsafe [2]. ...
... The reasons for foot-drop are anterior muscle weakness and/or spastic hyperactivity and/or contractures of the plantarflexor muscles [5]. The spasticity and contractures results further in excessive plantarflexion during stance phase of walking, leading to toe-gait and is present in 38% of unilaterally involved individuals with CP [3] and 18% of stroke survivors [6]. ...
Article
Background Foot-drop is a common impairment in individuals with upper motor neuron syndrome. It may cause walking instability, and greater risk of tripping and falling. Ankle–foot orthoses are the standard of care for foot-drop, but may constrain ankle movement and limit function. Functional electrical stimulation (FES) was shown to be a less restrictive and effective alternative. Previous studies have addressed the improvement of ankle dorsiflexion during swing and initial contact. However, the foot motion is 3-dimensional and if the stimulation of m. peroneus longus and m. tibialis anterior is not well balanced, excessive eversion or inversion of the foot can occur respectively. Therefore, the objective is to show the effect of FES on foot motion during walking. Methods Sixteen patients with an upper motor neuron syndrome, with a mean age of 15.7 (SD=8.7) years, GMFCS I and II and foot-drop were included. Gait analyses in FES and non-FES conditions were performed at preferred walking speed using the Oxford Foot Model. Differences between conditions were revealed using a t-test. Results Use of FES significantly increased peak dorsiflexion in swing phase during walking by 4.7̊ (SD=6.0̊). Eversion of the rearfoot and abduction of the forefoot significantly increased during initial ground contact by 3.7̊ (SD=4.9̊) and 1.9̊ (SD=2.2̊) respectively. This translates to a significant eversion and abduction of 1.4̊ (SD=2.7̊) and 1.3̊ (SD=2.1̊) during stance phase of walking. Conclusions FES aiming for improved dorsiflexion in swing, increases hindfoot eversion and forefoot abduction that translates into initial contact and persists, although to a lesser extent, during stance phase of walking. The consistent increase in rearfoot eversion may be due to the strategy of choosing higher stimulation intensity and accept exaggerated eversion. While this strategy provides a certain amount of safety and functionality, it affects foot kinematics during stance phase of walking. This can be advantageous for a clubfoot deformity and may have implications for their therapy but deteriorates an existing flatfoot deformity.
... Cerebral palsy (CP) is a heterogeneous and complex neuromuscular disorder that leads to different degrees of severity [1][2][3][4]. The extent of the secondary movement disorder, on the one hand, depends on the extent of the primary brain injury and its etiology, the extent of asymmetry and walking speed, and on the other hand, is positively influenced by plasticity and reorganization of neuronal networks and practice-induced improvements [5][6][7][8][9][10][11][12][13]. ...
Article
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A variety of gait pathologies is seen in cerebral palsy. Movement patterns between different levels of functional impairment may differ. The objective of this work was the evaluation of Gross Motor Function Classification System (GMFCS) level-specific movement disorders. A total of 89 individuals with unilateral cerebral palsy and no history of prior treatment were included and classified according to their functional impairment. GMFCS level-specific differences, kinematics and joint moments, exclusively of the involved side, were analyzed for all planes for all lower limb joints, including pelvic and trunk movements. GMFCS level I and level II individuals most relevantly showed equinus/reduced dorsiflexion moments, knee flexion/reduced knee extension moments, reduced hip extension moments with pronounced flexion, internal hip rotation and reduced hip abduction. Anterior pelvic tilt, obliquity and retraction were found. Individuals with GMFCS level II were characterized by an additional pronounced reduction in all extensor moments, pronounced rotational malalignment and reduced hip abduction. The most striking characteristics of GMFCS level II were excessive anterior pelvic/trunk tilt and excessive trunk obliquity. Pronounced reduction in extensor moments and excessive trunk lean are distinguishing features of GMFCS level II. These patients would benefit particularly from surgical treatment restoring pelvic symmetry and improving hip abductor leverage. Future studies exploring GMFCS level-specific compensation of the sound limb and GMFCS level-specific malalignment are of interest.
... Cerebral Palsy (CP) is a complex and heterogeneous disorder, leading to a variety of secondary musculoskeletal symptoms and deformities [1][2][3][4]. Specifically, in unilateral CP, other than in diplegic or quadriplegic CP, gait patterns may even depend on walking speed and on the extent of asymmetry [2,5,6]. Different classification systems (morphological and functional) have been developed in the past, in order to simplify treatment recommendations and decision-making [7][8][9][10]. ...
Article
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As cerebral palsy (CP) is a complex disorder, classification of gait pathologies is difficult. It is assumed that unclassified patients show less functional impairment and less gait deviation. The aim of this study was to assess the different subgroups and the unclassified patients with unilateral CP using different gait indices. The Gillette Gait Index (GGI), Gait Deviation Index (GDI), Gait Profile Score (GPS) and spatiotemporal parameters derived from instrumented 3D-Gait Analysis (IGA) were assessed. Subgroups were defined using morphological and functional classification systems. Regarding the different gait indices, a ranking of the different gait patterns is evident. Significant differences were found between GMFCS level I and II, Winters et al. (Winters, Gage, Hicks; WGH) type IV and type I and the WGH-unclassified. Concerning the spatiotemporal parameters significant differences were found between GMFCS level I and II concerning velocity. The unclassified patients showed mean values for the different gait indices that were comparable to those of established subgroups. Established gait patterns cause different degrees of gait deviation and functional impairment. The unclassified patients do not differ from established gait patterns but from the unimpaired gait. Further evaluation using 3D-IGA is necessary to identify the underlying gait pathologies of the unclassified patients.
... In contrast, the opto-reflective marker sets utilized for validation studies have typically used the Plug in Gait (PiG) (Vicon Peak ® , Oxford, UK) marker set [9,10]. The PiG is a widely utilized marker set in both able-bodied motion analysis [11,12], as well as prosthesis wearer scholarship [13][14][15]. ...
Article
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Validation testing is a necessary step for inertial measurement unit (IMU) motion analysis for research and clinical use. Optical tracking systems utilize marker models which must be precise in measurement and mitigate skin artifacts. Prosthesis wearers present challenges to optical tracking marker model choice. Seven participants were recruited and underwent simultaneous motion capture from two marker sets; Plug in Gait (PiG) and the Strathclyde Cluster Model (SCM). Variability of joint kinematics within and between subjects was evaluated. Variability was higher for PiG than SCM for all parameters. The within-subjects variability as reported by the average standard deviation (SD), was below 5.6° for all rotations of the hip on the prosthesis side for all participants for both methods, with an average of 2.1° for PiG and 2.5° for SCM. Statistically significant differences in joint parameters caused by a change in the protocol were evident in the sagittal plane (p < 0.05) on the amputated side. Trans-tibial gait analysis was best achieved by use of the SCM. The SCM protocol appeared to provide kinematic measurements with a smaller variability than that of the PiG. Validation studies for prosthesis wearer populations must reconsider the marker protocol for gold standard comparisons with IMUs.
... The type of the gait abnormality is influenced by the primary brain injury, secondary deformities or compensatory mechanisms [4,5,13]. Gait patterns may even depend on walking speed and on the extent of asymmetry [5,13,14]. Gait classification is very demanding but of high clinical relevance. In order to initiate an appropriate treatment and to avoid secondary problems like degeneration of cartilage and immobilization, gait disorders should be detected as soon and as precisely as possible. ...
Article
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As unilateral cerebral palsy represents a complex disorder, gait classification is difficult. Knowledge of the most frequent gait patterns and functional impairment is crucial for proper decision-making. This study analyzes the prevalence of gait patterns as well as the relation of different gait patterns and the Gross Motor Function Classification System (GMFCS). Eighty-nine patients were classified retrospectively using the GMFCS, the classification of Winters, Gage, and Hicks (WGH), and Sutherland et al. The distribution of GMFCS levels among the different gait patterns was analyzed using Chi-squared test. The most common subtypes were GMFCS level I, WGH type I, and recurvatum knee. Seventeen percent (WGH) and 59% (Sutherland) of the patients did not match any criteria. Applying both classifications complementarily reduced the number of unclassified patients significantly. There was no significant difference concerning the distribution of GMFCS levels or age among the different gait patterns. A combined use of various classification systems is beneficial for proper decision-making. Unclassified patients seem to be a heterogeneous subgroup concerning functional impairment. There is a need of further characterization of the unclassifiable gait patterns and the caused functional impairment. Instrumented gait analysis remains the gold standard and should be broadly used for future studies and in clinical practice.
Article
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Article
Purpose: This needs assessment survey identifies the priorities of the clinical and research communities involved with the use of instrumented gait analysis (IGA) for a clinical practice guideline on IGA use with children with cerebral palsy (CP). Methods: Thirteen Likert scale questions asked about the importance of topics related to IGA. Other questions addressed respondents' demographics, experience with IGA, patient populations, and gait laboratory characteristics. Several open-ended questions were included and analyzed. Results: The survey was completed by 43 physical therapists and 53 non-physical therapists involved with IGA. More than 90% rated the following as critically or highly important: reliability and validity of IGA to identify gait pathology (94%); ability to longitudinally track gait pathology (93%); use in planning interventions (93%); use in evaluating outcomes (93%); and definition of IGA (90%). Conclusions and recommendations for clinical practice: This needs assessment survey identified the topic priorities of clinicians and practitioners who use IGA for the management of children with CP. These results will guide the development of a clinical practice guideline on the use of IGA for the management of CP.
Article
Background: Spastic drop-foot is a common problem in children with cerebral palsy that may lead to tripping and falling. To improve ankle dorsiflexion in swing phase, prefabricated carbon-composite ankle-foot orthoses are commonly prescribed; by increasing ankle stiffness, these orthoses may also improve knee extension in stance. Objectives: To compare the effect of a stiff vs. flexible prefabricated ankle-foot orthosis on sagittal plane ankle and knee kinematics and kinetics during walking. Study design: Cross-sectional, repeated-measures, interventional study. Methods: Twenty-seven children and adolescents with cerebral palsy who had drop-foot in swing were included. Gait analysis was conducted under four conditions: barefoot, shod, with a stiff, and with a flexible orthosis. Participants were divided into two groups including children and adolescents who have a flexed knee during stance (KF, N = 12) and without flexed knee during stance (KE, N = 15). Results: Ankle dorsiflexion in swing phase was significantly improved compared with the shod condition by 6.3 degrees (SD = 3.3 degrees) only in the KE group when using the flexible orthosis. For the stiff orthosis, knee extension in stance was significantly increased by 2.4 degrees (SD = 3.3 degrees) in the KE group compared with the shod condition. No significant improvements were observed for the KF group. Further analysis indicated that only seven patients in the KF group with weak ankle plantarflexors improved knee extension while using the stiff orthosis. Conclusions: Our results suggested that in the KE group, the flexible orthosis was best suited for patients with drop-foot without a knee extension deficit. The stiff orthosis was not suitable in this group as it caused a hyperextended knee without improving dorsiflexion in swing phase. Therefore, stiffness should be considered when prefabricated orthoses are prescribed.
Article
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