Abstract
During a Delphi consensus study, a new joint gait classification system was developed for children with cerebral palsy (CP). This system, whose reliability and content validity have previously been established, identified 49 distinct joint patterns. The present study aims to provide a first insight toward the construct validity and clinical relevance of this classification system. The retrospective sample of convenience consisted of 286 patients with spastic CP (3–18 years old, GMFCS levels I–III, 166 with bilateral CP). Kinematic and kinetic trials from three-dimensional gait analysis were classified according to the definitions of the Delphi study, and one classified trial was randomly selected for each included limb (n = 446). Muscle weakness and spasticity were assessed for different muscle groups acting around the hip, knee, and ankle. Subsequently, Pearson Chi square tests, Cramer's V, and adjusted standardized residuals were calculated to explore the strength and direction of the associations between the joint patterns, and the different patient-specific characteristics (i.e., age, GMFCS level, and topographical classification) or clinical symptoms (muscle weakness and spasticity). Patient-specific characteristics showed several significant associations with the patterns of different joints, but the strength of most identified associations was weak. Apart from the knee during stance phase and the pelvis in the sagittal plane, the results systematically showed that the patterns with “minor gait deviations” were the most frequently observed. These minor deviations were found significantly more often in limbs with a lower level of spasticity and good muscle strength. Several other pathological joint patterns were moderately associated with weakness or spasticity, including but not limited to “outtoeing” for weakness and “intoeing” for spasticity. For the joints in the sagittal plane, significantly stronger associations were found with muscle weakness and spasticity, possibly because most of the evaluated muscles in this study mainly perform sagittal plane motions. Remarkably, the hip patterns in the coronal plane did not associate significantly with any of the investigated variables. Although further validation is warranted, this study contributes to the construct validity of the joint patterns of the Delphi consensus study, by demonstrating their ability to distinguish between clinically relevant subgroups in CP.
Highlights
Cerebral palsy (CP) is the result of a pre- or post-natal lesion in the developing brain of a fetus or child, primarily affecting motor behavior
The present study aims to provide a first insight toward the construct validity and clinical relevance of the aforementioned consensus-based joint patterns during gait in children with CP (Nieuwenhuys et al, 2016)
The sample contained a total of 459 sessions, which were all screened for the following inclusion criteria: (a) a diagnosis of unilateral or bilateral CP (b) predominantly spastic type of CP (c) 3–18 years of age, (d) Gross Motor Function Classification System (GMFCS)-level I–III, and (e) the availability of at least two good quality kinematic gait trials from three-dimensional gait analysis
Summary
Cerebral palsy (CP) is the result of a pre- or post-natal lesion in the developing brain of a fetus or child, primarily affecting motor behavior. The heterogenic clinical presentation of CP is emphasized, because of the numerous potential differences in timing, location, severity, and nature of brain lesions, and because it is continuously altered by a maturing brain, musculoskeletal growth, and treatment (Bax et al, 2005). Treatment-related, and many other reasons, it is important to identify relevant subgroups within the CP population. The Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System are used to classify the severity of lower and upper limb motor function impairment (Palisano et al, 1997; Eliasson et al, 2006), while emphasizing on everyday performance (Palisano et al, 1997). Even though the GMFCS is a generally accepted functionality score for children with CP, it is not detailed enough to cover all gait-related deviations (Õunpuu et al, 2015)
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