Gait In Children Research Articles

Effect of Coordinative Locomotor Training on Postural Imbalance and Gait in Children: A Single Subject Design

Effect of Coordinative Locomotor Training on Postural Imbalance and Gait in Children: A Single Subject Design

EMG-based Indicators of Muscular Co-Activation during Gait in Children with Duchenne Muscular Dystrophy.

Muscular weakness is one of the main signs associated with the onset and progression of Duchenne Muscular Dystrophy. During motor functions, this disease also determines deviations in muscular activity, especially in terms of coordination and activation between muscles acting on the same joints. In this study, surface EMG activity of the lower limb muscles of 10 children with Duchenne Muscular Dystrophy at different times from disease onset were recorded along with kinematics during unconstrained gait. Muscular co-activation of muscle pairs was then evaluated by extracting different co-activation indicators, and linking them with kinematic markers of motor function. The combination of disease progression and pharmacological treatment resulted in a significant decrease in terms of co-activation indexes for two pairs of agonist-antagonist muscles, and for one of these two pairs the decrease in co-activation was correlated with a decrease in the motor function of gait.

Real-Time Detection of Seven Phases of Gait in Children with Cerebral Palsy Using Two Gyroscopes.

A recently designed gait phase detection (GPD) system, with the ability to detect all seven phases of gait in healthy adults, was modified for GPD in children with cerebral palsy (CP). A shank-attached gyroscope sent angular velocity to a rule-based algorithm in LabVIEW to identify the distinct characteristics of the signal. Seven typically developing children (TD) and five children with CP were asked to walk on treadmill at their self-selected speed while using this system. Using only shank angular velocity, all seven phases of gait (Loading Response, Mid-Stance, Terminal Stance, Pre-Swing, Initial Swing, Mid-Swing and Terminal Swing) were reliably detected in real time. System performance was validated against two established GPD methods: (1) force-sensing resistors (GPD-FSR) (for typically developing children) and (2) motion capture (GPD-MoCap) (for both typically developing children and children with CP). The system detected over 99% of the phases identified by GPD-FSR and GPD-MoCap. Absolute values of average gait phase onset detection deviations relative to GPD-MoCap were less than 100 ms for both TD children and children with CP. The newly designed system, with minimized sensor setup and low processing burden, is cosmetic and economical, making it a viable solution for real-time stand-alone and portable applications such as triggering functional electrical stimulation (FES) in rehabilitation systems. This paper verifies the applicability of the GPD system to identify specific gait events for triggering FES to enhance gait in children with CP.

Biomechanical Outcomes Related with Gait in Children with Cerebral Palsy Using Ankle-Foot Orthotic - A Systematic Review

Gait in children with cerebral palsy (CP) is often affected by motor impairments which limit the patient's ability to walk. To improve gait and reduce walking limitations, children with CP need to use ankle foot orthoses. An orthosis is an externally applied device that is designed and fitted to the body to achieve one or more of the following goals: a) Control biomechanical alignment. b) Correct or accommodate deformity, and 3) Protect and support an injury. This systematic review aims to describe research evidence supporting the use of ankle-foot orthoses to improve gait biomechanical outcomes among individuals with CP. Literature search was pursued from PubMed database. Studies were included if (1) they evaluated an outcome measure related with gait using ankle-foot orthotic (AFO) in children (2) considered children with a diagnosis of CP and have a (3) GMFCS classification of I, II or III. Papers were excluded if they evaluated (1) other population besides CP, (2) the use of orthoses other than AFOs and (3) gait analysis procedure was not presented. All the included studies have analyzed spatiotemporal parameters, the step length (m), stride length (m) and cadence (steps/minute) were the most frequently reported. Our findings showed that several studies have investigated the effects of AFOs, all of which have reported positive influences on at least one gait parameter, as well as positive changes in joint kinematics and kinetic in children with CP.

Immediate Effects of Immersive Biofeedback on Gait in Children With Cerebral Palsy

ObjectiveTo investigate the immediate response to avatar-based biofeedback on 3 clinically important gait parameters: step length, knee extension, and ankle power in children with cerebral palsy (CP). DesignRepeated measures design. SettingRehabilitation clinic. ParticipantsChildren with spastic paresis (N=22; 10.5±3.1y), able to walk without assistive devices. InterventionChildren walked on a treadmill with a virtual reality environment. Following baseline gait analysis, they were challenged to improve aspects of gait. Children visualized themselves as an avatar, representing movement in real time. They underwent a series of 2-minute trials receiving avatar-based biofeedback on step length, knee extension, and ankle power. To investigate optimization of biofeedback visualization, additional trials in which knee extension was visualized as a simple bar with no avatar; and avatar alone with no specific biofeedback were carried out. Main Outcome MeasuresGait pattern, as measured by joint angles, powers, and spatiotemporal parameters, were compared between baseline and biofeedback trials. ResultsParticipants were able to adapt gait pattern with biofeedback, in an immediate response, reaching large increases in ankle power generation at push-off (37.7%) and clinically important improvements in knee extension (7.4o) and step length (12.7%). Biofeedback on one parameter had indirect influence on other aspects of gait. ConclusionChildren with CP show capacity in motor function to achieve improvements in clinically important aspects of gait. Visualizing biofeedback with an avatar was subjectively preferential compared to a simplified bar presentation of knee angle. Future studies are required to investigate if observed transient effects of biofeedback can be retained with prolonged training to test whether biofeedback-based gait training may be implemented as a therapy tool.

Head and Trunk Movements During Turning Gait in Children with Cerebral Palsy

Thirty children with cerebral palsy (CP) and 22 typical developing (TD) were tested with 3D-gait analysis. At turning, trunk rotation was larger in CP2 (GMFCS II) than in TD and CP1 (GMFCS I), and head flexion was larger in CP3 (GMFCS III) than TD. Maximum head and trunk flexion values during the entire trial were larger in CP3 than in the other groups, and trunk flexion was larger in CP2 than in TD. Trial time increased with GMFCS-level. Less trunk rotation than TD and CP1 reflects spatial insecurity in CP2, which in CP3 is compensated by the walker. The flexed head and trunk in CP3 and trunk in CP2 may reflect deficits in proprioception and sensation requiring visual control of the lower limbs.

Correction of Toe-Walking Gait in Children with Spastic Cerebral Palsy by using Electrical Stimulation Therapy.

Toe-walking is a very common gait abnormality seen in children with Cerebral Palsy (CP). The present study aims to improvise the toe-walking gait by applying Electrical Stimulation (ES) therapy of the Tricep Surae (TS) muscles. The study was carried out on sixteen children with spastic CP with unilateral toe-walking gait problem, divided into the intervention group that received both ES therapy along with conventional physiotherapy treatment and the control group that received only conventional physiotherapy treatment. Both groups were treated for 60 (30 + 30) minutes per day, for 5 days a week, up to 12 weeks. The gait data were analyzed for spatiotemporal and parameters influencing the walking capacity. The results showed that those children who received the intervention had a significant increase in gait speed by 17.67 % (p = 0.019) and decrease in stride length by 10.25 % (p = 0.037), resulting in improvement of body balance. There was a significant percentage increase in initial contact (heel strike) of 85.71 % (p = 0.000) and flat foot position (loading response) of 49.2 % (p = 0.005), confirming reduction in toe-walking. There was also an increase in the swing power by 39.8 % (p = 0.028) and ground impact by 19.5 % (p = 0.003) suggesting a change in foot contact pattern. The results indicate that ES therapy on TS muscle along with conventional physiotherapy may correct the toe-walking gait in children with spastic hemiplegic CP.

Repeatability of EMG activity during exoskeleton assisted walking in children with cerebral palsy: implications for real time adaptable control.

Effective solutions for gait rehabilitation in children with cerebral palsy (CP) remain elusive. Wearable robotic exoskeletons offer the potential to greatly increase the dosage and intensity of gait training in this population, which may improve outcomes. We recently reported that a robotic exoskeleton significantly improved knee extension in children with crouch gait from CP. Longitudinal studies are necessary to fully understand long term biomechanical effects of exoskeleton gait training. Given that children's gait can change both as they develop and throughout their therapy, advanced control strategies which can adapt assistance over time may be beneficial. But, stride-to-stride variability makes it difficult to ascertain the effects of exoskeleton assistance and therefore complicates implementation of adaptable control algorithms. Here, we examine the use of the variance ratio (VR), a previously published measure, to assess the effect of exoskeleton assistance on knee extensor and flexor EMG variability in children with CP. Our results show that VR was significantly increased ($p<0.001)$ compared to baseline during walking with exoskeleton assistance. After five practice sessions, we found that VR was reduced though still greater than baseline levels. Given its sensitivity to exoskeleton assistance and ease of computation, VR may be a useful measure in the future for evaluating stride-to-stride variability in real time to inform algorithmic decision making for autonomous adaptable control.

Dynamic Balance During Gait in Children With Spastic Diplegic Cerebral Palsy Versus Normal Children

Dynamic Balance During Gait in Children With Spastic Diplegic Cerebral Palsy Versus Normal Children

Quantitative Assessment of Knee Progression Angle During Gait in Children With Cerebral Palsy.

Abnormal hip rotation is a common deviation in children with cerebral palsy (CP). Clinicians typically assess hip rotation during gait by observing the direction that the patella points relative to the path of walking, which is referred to as the knee progression angle (KPA). Two kinematic methods for calculating the KPA are compared with each other. Video-based qualitative assessment of KPA is compared with the quantitative methods to determine reliability and validity. The KPA was calculated by both direct and indirect methods for 32 typically developing (TD) children and a convenience cohort of 43 children with hemiplegic type CP. An additional convenience cohort of 26 children with hemiplegic type CP was selected for qualitative assessment of KPA, performed by 3 experienced clinicians, using 3 categories (internal, >10 degrees; neutral, -10 to 10 degrees; and external, >-10 degrees). Root mean square (RMS) analysis comparing the direct and indirect KPAs was 1.14+0.43 degrees for TD children, and 1.75+1.54 degrees for the affected side of children with CP. The difference in RMS among the 2 groups was statistically, but not clinically, significant (P=0.019). Intraclass correlation coefficient revealed excellent agreement between the direct and indirect methods of KPA for TD and CP children (0.996 and 0.992, respectively; P<0.001).For the qualitative assessment of KPA there was complete agreement among all examiners for 17 of 26 cases (65%). Direct KPA matched for 49 of 78 observations (63%) and indirect KPA matched for 52 of 78 observations (67%). The RMS analysis of direct and indirect methods for KPA was statistically but not clinically significant, which supports the use of either method based upon availability. Video-based qualitative assessment of KPA showed moderate reliability and validity. The differences between observed and calculated KPA indicate the need for caution when relying on visual assessments for clinical interpretation, and demonstrate the value of adding KPA calculation to standard kinematic analysis. Level II-diagnostic test.

Rectus Femoris Transfer Versus Rectus Intramuscular Lengthening for the Treatment of Stiff Knee Gait in Children With Cerebral Palsy.

Rectus femoris transfer (RFT) is used to treat stiff knee gait in spastic cerebral palsy. Recently, rectus femoris lengthening has been reported as treatment for stiff knee gait. The purpose of this study was to compare short-term outcomes of 2 surgical procedures. A retrospective chart review of 23 patients (42 limbs) with diplegic spastic cerebral palsy who had undergone rectus femoris intramuscular lengthening for treatment of stiff knee gait with a Gross Motor Function Classification System level I, II, or III was completed. These patients were matched with a cohort of 23 patients (42 limbs) who had undergone RFTs based on age, sex, Gross Motor Function Classification System level, diagnosis, preoperative Gait Deviation Index, and any simultaneous surgeries. Preoperative and 1 year postoperative motion analysis data and physical examination were compared. There were no significant differences in demographics between the groups. On physical examination, a positive postoperative Duncan-Ely test was seen significantly less often in the transfer limbs (20 vs. 37). Average postoperative quad tone score was 1.56 for the transfer group compared with 2.19 for the lengthening group. No significant postoperative difference was seen between groups in stride length, walking speed, cadence, knee flexion at initial contact, peak knee flexion during loading response, mean knee flexion in stance, peak knee flexion in swing, time to peak knee flexion (% swing), time to peak knee flexion (% gait cycle), Gait Deviation Index or total knee range of motion. There was a difference in time to achieve 90 degrees passive knee flexion with the lengthening group reaching this in 8.3 days and transfer group in 15.3 days (P<0.0001). Motion analysis parameters showed results of RFT and rectus femoris intramuscular lengthening to be equivalent 1 year postoperatively. Since rectus femoris lengthening is technically less difficult and rehabilitation faster, rectus femoris lengthening may be preferred if long-term follow-up supports these findings. Level III-retrospective comparative study.

Pathological Movements of the Pelvis and Trunk During Gait in Children With Cerebral Palsy: A Cross-Sectional Study With 3-Dimensional Kinematics and Lower Lumbar Spinal Loading

Increased loading at the lumbar spine, particularly in the coronal plane, has been reported in children with cerebral palsy (CP). As pelvic and trunk movements associated with Trendelenburg and Duchenne type gait are most significant in the coronal plane, the potential exists for lower lumbar spinal loading to be negatively affected in children with CP and these types of movement patterns. The objective of this study was to assess trunk and pelvic kinematics and lower lumbar spinal loading patterns in children with CP and Trendelenburg and Duchenne type gait. This was a cross-sectional study. Three-dimensional kinematic (lower limb and thorax) and L5-S1 kinetic data were recorded. Children were divided according to clinical presentation of Trendelenburg or Duchenne type gait. Several discrete kinematic and kinetic parameters were assessed between groups. Three distinct pelvic and trunk movement patterns were identified for children with CP: Trendelenburg, Duchenne, and complex Trendelenburg-Duchenne. Peak L5-S1 lateral bending moments were increased by 62% in children with CP and Duchenne type gait. Children with CP and complex Trendelenburg-Duchenne gait demonstrated the largest deviations from normal, with increased peak ipsilateral and contralateral directed moments of 69% and 54%, respectively, compared with children with typical development. A test-retest reliability analysis or measure of minimal detectable change was not conducted as part of this study. Results suggest that measures of minimal detectable change may be high for some of the reported variables. In addition, the inverse dynamic approach determines only the net intersegmental reactive forces that reflect the effect of external loads. Previous studies have shown that spinal loads may be larger than the net intersegmental force. Trendelenburg and Duchenne type movements were not always distinct, and a third type of movement, a combination of the two, was the most common in this study. Clinicians should be aware that children with CP and the Duchenne type or the complex Trendelenburg-Duchenne type of gait pattern experience abnormal loading that may have significant implications for the lower spine in the long term.

Interrater reliability of two gait performance measures in children with neuromotor disorders across two different settings.

To examine the interrater agreement of the two gait performance measures - the Functional Mobility Scale (FMS) and Gillette Functional Assessment Questionnaire - walking scale (FAQ) - within health professionals and parents in children with neuromotor disorders, measured in an inpatient setting and at home. Seventy-one children with a neuromotor diagnosis (44 males, 27 females; median age 12y 11mo [interquartile range 4y-10mo]) were consecutively recruited when starting an inpatient active gait rehabilitation programme. Physiotherapists and nurses independently scored the level of children's gait performance with the FMS and the FAQ, while parents' scores regarding the children's gait performance at home were obtained by interview or telephone call at the same measurement points. Linear weighted kappa coefficients were substantial to almost perfect for all comparisons. Kappa coefficients ranged from 0.62 to 0.85 for the FMS-5, from 0.79 to 0.92 for the FMS-50, from 0.83 to 0.90 for the FMS-500, and from 0.69 to 0.77 for the FAQ. Friedman tests did not reveal significant differences between the different rater groups. The unexpectedly high level of interrater agreement between parents, physiotherapists, and nurses demonstrates that the FMS and FAQ can reliably assess gait performance in an inpatient setting. Inpatient scores correspond well to the children's performance in their usual environment. The Functional Mobility Scale and Gillette Functional Assessment Questionnaire - walking scale measure gait performance reliably at home and in an inpatient setting. Physiotherapists, nurses, and parents reliably score gait performance. Inpatient gait performance scores correspond well to children's performance at home. Physiotherapists and nurses in an inpatient setting can reliably estimate gait performance at home.

Attentional load of walking in children aged 7–12 and in adults

The amount of attentional resources necessary to walk in children, and how they evolve during childhood remains unclear. This study examined children's gait parameters in different dual-task conditions. 53 children, divided into two age groups (7–9 and 10–12 years old), and 18 adults walked on a mat in three different cognitive conditions: watching a video (video condition), listening its soundtrack (audio condition), and without any additional task (control condition). Questions were asked at the end of the video and audio conditions to make sure that participants were paying attention to the stimuli. A GAITRite® system was used for recording the gait data. Results showed an increase of velocity and step duration, and a decrease of cadence and percentage of double limb support duration from 7 years of age to adulthood during dual-task walking compared with single-task walking. This improvement seemed to be linear from 7 years to adults' age. The interference of dual-task on gait was larger for the video than for the auditory task and decreased with age. We concluded that walking requires a significant amount of attentional resources in children and that children rely more than adults on visual processes for walking.

Rectus Femoris Transfer Surgery Worsens Crouch Gait in Children With Cerebral Palsy at GMFCS Levels III and IV.

Previous study has shown that children with cerebral palsy (CP) functioning at Gross Motor Function Classification System (GMFCS) levels III and IV do not benefit from distal rectus femoris transfer (DRFT) due to lack of improvement in stance knee extension. The fate of knees in such subjects who do not undergo DRFT is unknown. The purpose of this study was to compare knee kinematic outcomes in patients with CP and stiff knee gait who underwent single-event multilevel surgery with and without DRFT. Preoperative and postoperative gait analysis data were retrospectively reviewed for ambulatory (GMFCS levels I to IV) patients with CP with crouch and stiff knee gait whom underwent single-event multilevel surgery, including hamstring lengthening either with DRFT (N=34) or without DRFT (N=40). Statistical analyses included t tests and χ tests, and multiple regression analysis was performed to adjust for covariates. Data were stratified by GMFCS level groups I/II and III/IV. Improved maximum knee extension in stance was seen for both the DRFT (P=0.0002) and no DRFT groups (P≤0.0006) at GMFCS levels I/II, and the no DRFT group at GMFCS levels III/IV (P=0.02). Excessive stance knee flexion persisted for those at GMFCS level III/IV after DRFT. Maximum knee flexion in swing was maintained after DRFT, but significantly decreased in the no DRFT group (P<0.002) for both GMFCS groups. Change in total knee range of motion improved after DRFT only in the GMFCS I/II group subjects with unilateral involvement (P=0.01). Timing of maximum knee flexion in swing improved for all patients regardless of DRFT or GMFCS level group (P<0.0001). In patients with CP functioning at GMFCS levels III and IV, DRFT results in persistent crouch postoperatively. Given the importance of maintaining upright posture in these patients, we do not recommend DRFT in patients functioning at GMFCS levels III and IV. Level III-retrospective comparative study.

Gait in Children with Attention-Deficit Hyperactivity Disorder in a Dual-Task Paradigm.

The aim was to examine gait in school-aged children with attention-deficit hyperactivity disorder (ADHD) and typically developing controls in a dual-task paradigm. Thirty children with ADHD (without or off medication) aged 7–13 years and 28 controls walked without an additional task (single-task walking) and while performing a concurrent cognitive or motor task (dual-task walking). Gait was assessed using GAITRite recordings of spatiotemporal and variability gait parameters. Compared to single-task walking, dual-tasking significantly altered walking performance of children with and without ADHD, whereby dual-task effects on gait were not different between the two groups. For both children with ADHD and controls the motor concurrent task had a stronger effect on gait than the cognitive concurrent task. Gait in children with and without ADHD is affected in a dual-task paradigm indicating that walking requires executive functions. Future investigations of children's dual-task walking should account for the type of concurrent tasks.

Statistical Parametric Mapping to Identify Differences between Consensus-Based Joint Patterns during Gait in Children with Cerebral Palsy.

Experts recently identified 49 joint motion patterns in children with cerebral palsy during a Delphi consensus study. Pattern definitions were therefore the result of subjective expert opinion. The present study aims to provide objective, quantitative data supporting the identification of these consensus-based patterns. To do so, statistical parametric mapping was used to compare the mean kinematic waveforms of 154 trials of typically developing children (n = 56) to the mean kinematic waveforms of 1719 trials of children with cerebral palsy (n = 356), which were classified following the classification rules of the Delphi study. Three hypotheses stated that: (a) joint motion patterns with ‘no or minor gait deviations’ (n = 11 patterns) do not differ significantly from the gait pattern of typically developing children; (b) all other pathological joint motion patterns (n = 38 patterns) differ from typically developing gait and the locations of difference within the gait cycle, highlighted by statistical parametric mapping, concur with the consensus-based classification rules. (c) all joint motion patterns at the level of each joint (n = 49 patterns) differ from each other during at least one phase of the gait cycle. Results showed that: (a) ten patterns with ‘no or minor gait deviations’ differed somewhat unexpectedly from typically developing gait, but these differences were generally small (≤3°); (b) all other joint motion patterns (n = 38) differed from typically developing gait and the significant locations within the gait cycle that were indicated by the statistical analyses, coincided well with the classification rules; (c) joint motion patterns at the level of each joint significantly differed from each other, apart from two sagittal plane pelvic patterns. In addition to these results, for several joints, statistical analyses indicated other significant areas during the gait cycle that were not included in the pattern definitions of the consensus study. Based on these findings, suggestions to improve pattern definitions were made.

DELAY ON GAIT PATTERNS ON DOWN SYNDROME CHILDREN

ABSTRACT The main purpose was to compare the spatiotemporal variables of the gait cycle in children with Down Syndrome as a function of age. A longitudinal study was conducted with 20 children, of both genders, aged between 24 and 83 months. Conventional techniques were used in the methodological procedures to record the children's anthropometry and two-dimensional cinematographic techniques for quantification of the spatiotemporal variables of their gait in relation to the global and partial variables. The results showed differences in the behavior of the anthropometric and kinematic variables, stride time, stride frequency, and time of first simple support in children with Down Syndrome between the age of 24-59 months and 60-83 months. The children's gait pattern over the years was established by the changes in frequency instead of the changes in the stride length for the development of gait speed. In conclusion the Behavior modifications in the anthropometric and spatiotemporal variables of the gait in children with Down Syndrome appear to be barely evident between 24 and 59 months of age.

Commentary on “Influence of External Visual Focus on Gait in Children With Bilateral Cerebral Palsy”

Commentary on “Influence of External Visual Focus on Gait in Children With Bilateral Cerebral Palsy”

5.3 What is so Odd About the Gait of Children With Autism Spectrum Disorder?

5.3 What is so Odd About the Gait of Children With Autism Spectrum Disorder?